Provider Demographics
NPI:1184795577
Name:SOUTHSIDE DRUGS INC
Entity type:Organization
Organization Name:SOUTHSIDE DRUGS INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VP
Authorized Official - Prefix:
Authorized Official - First Name:BEN
Authorized Official - Middle Name:
Authorized Official - Last Name:BRADDY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:478-453-7227
Mailing Address - Street 1:200 W ANDREWS ST
Mailing Address - Street 2:
Mailing Address - City:MILLEDGEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31061-3839
Mailing Address - Country:US
Mailing Address - Phone:478-453-7227
Mailing Address - Fax:478-452-9789
Practice Address - Street 1:200 W ANDREWS ST
Practice Address - Street 2:
Practice Address - City:MILLEDGEVILLE
Practice Address - State:GA
Practice Address - Zip Code:31061-3839
Practice Address - Country:US
Practice Address - Phone:478-453-7227
Practice Address - Fax:478-452-9789
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-10
Last Update Date:2016-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
GAPHRE0072213336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2017479OtherPK
GA00439227AMedicaid