Healthcare Provider Details

I. General information

NPI: 1912944844
Provider Name (Legal Business Name): SOUTH SIDE PHARMACY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/31/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6905 S WENTWORTH AVE
CHICAGO IL
60621-3734
US

IV. Provider business mailing address

6905 S WENTWORTH AVE
CHICAGO IL
60621-3734
US

V. Phone/Fax

Practice location:
  • Phone: 773-723-2500
  • Fax:
Mailing address:
  • Phone: 773-723-2500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number StateIL

VIII. Authorized Official

Name: TONY DIORIO
Title or Position: VICE PRESIDENT
Credential:
Phone: 815-834-0020