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General NPI Number Information
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NPI Number | 1104186212
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Entity Type | Organization
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Legal Business Name | SOUTHSIDE PHARMACY LLC
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Dates
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Enumeration Date | 05/22/2012
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Last Update Date | 01/17/2014
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Provider Practice Location Address
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Address Line | 3320 4TH AVE STE F
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City | CONWAY
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State | SC
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Zip | 29527-6057
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Country | US
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Telephone | 843-248-6550
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Fax | 843-248-6553
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Provider Business Mailing Address
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Address Line | 3320 4TH AVE STE F
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City | CONWAY
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State | SC
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Zip | 29527-6057
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Country | US
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Telephone | 843-248-6550
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Fax | 843-248-6553
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Authorized Official
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Title or Position | PRESIDENT/PHARMACIST IN CHARGE
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Name | JOHNNY CAPPS
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Credential |
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Telephone | 843-248-6550
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number | 13996
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License Number State | SC
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