Provider Demographics
NPI:1104186212
Name:SOUTHSIDE PHARMACY LLC
Entity Type:Organization
Organization Name:SOUTHSIDE PHARMACY LLC
Other - Org Name:SOUTHSIDE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/PHARMACIST IN CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:JOHNNY
Authorized Official - Middle Name:
Authorized Official - Last Name:CAPPS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-248-6550
Mailing Address - Street 1:3320 4TH AVE STE F
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:SC
Mailing Address - Zip Code:29527-6057
Mailing Address - Country:US
Mailing Address - Phone:843-248-6550
Mailing Address - Fax:843-248-6553
Practice Address - Street 1:3320 4TH AVE STE F
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:SC
Practice Address - Zip Code:29527-6057
Practice Address - Country:US
Practice Address - Phone:843-248-6550
Practice Address - Fax:843-248-6553
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-22
Last Update Date:2014-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC139963336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2135319OtherPK
SC71399DMedicaid