MEDICARE: SOUTHSIDE PHARMACY LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3336C0003X	Community/Retail Pharmacy	13996	SC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2135319	OTHER		PK
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1104186212
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHSIDE PHARMACY LLC

Provider Business Mailing Address
First Line	:	3320 4TH AVE STE F
Second Line	:
City	:	CONWAY
State	:	SC
Zip	:	29527-6057
Country	:	US
Telephone Number	:	843-248-6550
Fax Number	:	843-248-6553

Provider Business Practice Location Address
First Line	:	3320 4TH AVE STE F
Second Line	:
City	:	CONWAY
State	:	SC
Zip	:	29527-6057
Country	:	US
Telephone Number	:	843-248-6550
Fax Number	:	843-248-6553

Authorized Official
Title or Position	:	PRESIDENT/PHARMACIST IN CHARGE
Name	:	JOHNNY CAPPS
Credential	:
Telephone Number	:	843-248-6550

Provider Enumeration Date	:	05/22/2012
Last Update Date	:	01/17/2014

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Directions to “SOUTHSIDE PHARMACY LLC ” Practice Location

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