MEDICARE: SOUTH SIDE 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	3336C0003X	Community/Retail Pharmacy		IL
2	333600000X	Pharmacy		IL

General Provider Information

NPI Number	:	1912944844
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTH SIDE PHARMACY, INC.

Provider Business Mailing Address
First Line	:	6905 S WENTWORTH AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60621-3734
Country	:	US
Telephone Number	:	773-723-2500
Fax Number	:

Provider Business Practice Location Address
First Line	:	6905 S WENTWORTH AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60621-3734
Country	:	US
Telephone Number	:	773-723-2500
Fax Number	:

Authorized Official
Title or Position	:	VICE PRESIDENT
Name	:	TONY DIORIO
Credential	:
Telephone Number	:	815-834-0020

Provider Enumeration Date	:	05/31/2006
Last Update Date	:	09/11/2025

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