Provider Demographics
NPI:1104908359
Name:SOUTHSIDE PHARMACY
Entity type:Organization
Organization Name:SOUTHSIDE PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:
Authorized Official - Last Name:SEIBER
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:270-383-3784
Mailing Address - Street 1:102 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:EARLINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:42410-1334
Mailing Address - Country:US
Mailing Address - Phone:270-383-3784
Mailing Address - Fax:270-383-3297
Practice Address - Street 1:102 E MAIN ST
Practice Address - Street 2:
Practice Address - City:EARLINGTON
Practice Address - State:KY
Practice Address - Zip Code:42410-1334
Practice Address - Country:US
Practice Address - Phone:270-383-3784
Practice Address - Fax:270-383-3297
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY011354183500000X
KYP066443336C0003X, 332BX2000X, 332B00000X, 332BC3200X, 333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Not Answered3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Not Answered332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Not Answered332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Not Answered332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Not Answered333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY54002274Medicaid
KY54002274Medicaid