Provider Demographics
NPI:1942765284
Name:SOUTH SIDE DRUG INC
Entity Type:Organization
Organization Name:SOUTH SIDE DRUG INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE-PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:L
Authorized Official - Last Name:FRAHM
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:641-682-3467
Mailing Address - Street 1:337 CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:OTTUMWA
Mailing Address - State:IA
Mailing Address - Zip Code:52501-4294
Mailing Address - Country:US
Mailing Address - Phone:641-682-3467
Mailing Address - Fax:641-682-8822
Practice Address - Street 1:337 CHURCH ST
Practice Address - Street 2:
Practice Address - City:OTTUMWA
Practice Address - State:IA
Practice Address - Zip Code:52501-4294
Practice Address - Country:US
Practice Address - Phone:641-682-3467
Practice Address - Fax:641-682-8822
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOUTH SIDE DRUG INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-01-31
Last Update Date:2019-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy