Provider Demographics
NPI:1992105472
Name:SOUTHSIDE PHARMACY OF LORAIN INC
Entity type:Organization
Organization Name:SOUTHSIDE PHARMACY OF LORAIN INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NASER
Authorized Official - Middle Name:
Authorized Official - Last Name:TAHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:440-277-0655
Mailing Address - Street 1:2811 FULTON RD
Mailing Address - Street 2:STE B
Mailing Address - City:LORAIN
Mailing Address - State:OH
Mailing Address - Zip Code:44055-1638
Mailing Address - Country:US
Mailing Address - Phone:440-277-0655
Mailing Address - Fax:440-277-0651
Practice Address - Street 1:2811 FULTON RD
Practice Address - Street 2:STE B
Practice Address - City:LORAIN
Practice Address - State:OH
Practice Address - Zip Code:44055-1638
Practice Address - Country:US
Practice Address - Phone:440-277-0655
Practice Address - Fax:440-277-0651
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-03
Last Update Date:2014-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0224475503336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2148083OtherPK
OH0113462Medicaid