Provider Demographics
NPI:1548544752
Name:SOUTHSIDE PHARMACY INC
Entity type:Organization
Organization Name:SOUTHSIDE PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TAMMY
Authorized Official - Middle Name:
Authorized Official - Last Name:GARRETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:256-232-6588
Mailing Address - Street 1:11964 ESCUE DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:TANNER
Mailing Address - State:AL
Mailing Address - Zip Code:35671-3679
Mailing Address - Country:US
Mailing Address - Phone:256-232-6588
Mailing Address - Fax:256-232-6589
Practice Address - Street 1:11964 ESCUE DR STE A
Practice Address - Street 2:
Practice Address - City:TANNER
Practice Address - State:AL
Practice Address - Zip Code:35671-3680
Practice Address - Country:US
Practice Address - Phone:256-232-6588
Practice Address - Fax:256-232-6589
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-06
Last Update Date:2016-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
AL1138103336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2132353OtherPK
AL134219Medicaid
AL180019Medicaid
AL7403830001Medicare NSC