Provider Demographics
NPI:1114069911
Name:WEST SIDE COMMUNITY HEALTH SERVICES INC
Entity Type:Organization
Organization Name:WEST SIDE COMMUNITY HEALTH SERVICES INC
Other - Org Name:WESTSIDE COMMUNITY HEALTH SERVICES PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY SERVICES MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DIRK
Authorized Official - Middle Name:
Authorized Official - Last Name:KILLELEA
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:651-389-2415
Mailing Address - Street 1:POB 9830
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84109-9913
Mailing Address - Country:US
Mailing Address - Phone:651-602-7589
Mailing Address - Fax:651-602-7502
Practice Address - Street 1:153 CESAR CHAVEZ ST
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55107-2226
Practice Address - Country:US
Practice Address - Phone:651-602-7589
Practice Address - Fax:651-602-7502
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-12
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MN2620843336C0002X, 3336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2048314OtherPK
MN836253000Medicaid