Provider Demographics
NPI:1013982446
Name:WESTSIDE PHARMACY INC
Entity Type:Organization
Organization Name:WESTSIDE PHARMACY INC
Other - Org Name:JAKS PUBLIC PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:GLASSFORD
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:419-352-6423
Mailing Address - Street 1:970 W WOOSTER ST
Mailing Address - Street 2:SUITE #121
Mailing Address - City:BOWLING GREEN
Mailing Address - State:OH
Mailing Address - Zip Code:43402-2643
Mailing Address - Country:US
Mailing Address - Phone:419-352-6423
Mailing Address - Fax:419-353-8283
Practice Address - Street 1:970 W WOOSTER ST
Practice Address - Street 2:SUITE #121
Practice Address - City:BOWLING GREEN
Practice Address - State:OH
Practice Address - Zip Code:43402-2643
Practice Address - Country:US
Practice Address - Phone:419-352-6423
Practice Address - Fax:419-353-8283
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2018104Medicaid