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General NPI Number Information
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NPI Number | 1992105472
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Entity Type | Organization
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Legal Business Name | SOUTHSIDE PHARMACY OF LORAIN INC
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Dates
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Enumeration Date | 09/03/2014
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Last Update Date | 12/30/2014
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Provider Practice Location Address
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Address Line | 2811 FULTON RD STE B
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City | LORAIN
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State | OH
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Zip | 44055-1638
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Country | US
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Telephone | 440-277-0655
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Fax | 440-277-0651
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Provider Business Mailing Address
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Address Line | 2811 FULTON RD STE B
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City | LORAIN
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State | OH
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Zip | 44055-1638
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Country | US
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Telephone | 440-277-0655
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Fax | 440-277-0651
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Authorized Official
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Title or Position | OWNER
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Name | NASER TAHER
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Credential |
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Telephone | 440-277-0655
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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 | 022447550
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License Number State | OH
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