Provider Demographics
NPI:1396753927
Name:SOUTHSIDE FAMILY PHARMACY INC
Entity type:Organization
Organization Name:SOUTHSIDE FAMILY PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:
Authorized Official - Last Name:BOGGS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:256-413-4473
Mailing Address - Street 1:1250 HIGHWAY 77
Mailing Address - Street 2:
Mailing Address - City:SOUTHSIDE
Mailing Address - State:AL
Mailing Address - Zip Code:35907-0405
Mailing Address - Country:US
Mailing Address - Phone:256-413-4473
Mailing Address - Fax:256-413-7358
Practice Address - Street 1:1250 HIGHWAY 77
Practice Address - Street 2:
Practice Address - City:SOUTHSIDE
Practice Address - State:AL
Practice Address - Zip Code:35907-0405
Practice Address - Country:US
Practice Address - Phone:256-413-4473
Practice Address - Fax:256-413-7358
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-03
Last Update Date:2021-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
AL1121703336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL142548Medicaid
2137549OtherPK
AL142548Medicaid