Provider Demographics
NPI:1275511362
Name:WESTSIDE PHARMACY, INC.
Entity Type:Organization
Organization Name:WESTSIDE PHARMACY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SUPERVISING PHARMACIST OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DAWN
Authorized Official - Middle Name:CANNON
Authorized Official - Last Name:WEST
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:334-699-6337
Mailing Address - Street 1:4440 W MAIN ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36305-1064
Mailing Address - Country:US
Mailing Address - Phone:334-699-6337
Mailing Address - Fax:334-699-6338
Practice Address - Street 1:4440 W MAIN ST
Practice Address - Street 2:SUITE 1
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36305-1064
Practice Address - Country:US
Practice Address - Phone:334-699-6337
Practice Address - Fax:334-699-6338
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL112724332B00000X, 333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Not Answered333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL5572250001Medicare ID - Type Unspecified