Healthcare Provider Details

I. General information

NPI: 1356257083
Provider Name (Legal Business Name): SOUTHSIDE COMMUNITY HEALTH SERVICES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/21/2026
Last Update Date: 08/21/2026
Certification Date: 08/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 E LAKE ST
MINNEAPOLIS MN
55407-1617
US

IV. Provider business mailing address

1000 E LAKE ST
MINNEAPOLIS MN
55407-1617
US

V. Phone/Fax

Practice location:
  • Phone: 612-384-9248
  • Fax:
Mailing address:
  • Phone: 612-384-9248
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: STACY FERDERER
Title or Position: DIRECTOR OF PHARMACY
Credential: PHARMD
Phone: 612-384-9248