Provider Demographics
NPI:1386761757
Name:WESTSIDE FAMILY PHARMACY INC
Entity type:Organization
Organization Name:WESTSIDE FAMILY PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER, PIC
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:RAGAN
Authorized Official - Suffix:
Authorized Official - Credentials:PHRM
Authorized Official - Phone:479-756-3232
Mailing Address - Street 1:3819 W SUNSET AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGDALE
Mailing Address - State:AR
Mailing Address - Zip Code:72762-4959
Mailing Address - Country:US
Mailing Address - Phone:479-756-3232
Mailing Address - Fax:479-756-1217
Practice Address - Street 1:3819 W SUNSET AVE
Practice Address - Street 2:
Practice Address - City:SPRINGDALE
Practice Address - State:AR
Practice Address - Zip Code:72762-4959
Practice Address - Country:US
Practice Address - Phone:479-756-3232
Practice Address - Fax:479-756-1217
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-23
Last Update Date:2014-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 3336C0004X
ARAR205563336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR187155716Medicaid
1989788OtherPK
AR163497407Medicaid
1989788OtherPK