MEDICARE: SOUTHSIDE FAMILY PHARMACY INC

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	333600000X	Pharmacy
2	3336C0003X	Community/Retail Pharmacy	112170	AL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	2137549	OTHER		PK

General Provider Information

NPI Number	:	1396753927
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHSIDE FAMILY PHARMACY INC

Provider Business Mailing Address
First Line	:	1250 HIGHWAY 77
Second Line	:
City	:	SOUTHSIDE
State	:	AL
Zip	:	35907-0405
Country	:	US
Telephone Number	:	256-413-4473
Fax Number	:	256-413-7358

Provider Business Practice Location Address
First Line	:	1250 HIGHWAY 77
Second Line	:
City	:	SOUTHSIDE
State	:	AL
Zip	:	35907-0405
Country	:	US
Telephone Number	:	256-413-4473
Fax Number	:	256-413-7358

Authorized Official
Title or Position	:	OWNER
Name	:	TRACY BOGGS
Credential	:
Telephone Number	:	256-413-4473

Provider Enumeration Date	:	08/03/2006
Last Update Date	:	01/14/2021

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