| Name: | SOUTHSIDE FAMILY PHARMACY, INC |
| Jurisdiction: | Alabama |
| Legal type: | Domestic Corporation |
| Status: | Exists |
| Date of registration: | 23 Jul 2012 (12 years ago) |
| Entity Number: | 000-072-322 |
| Register Number: | 000072322 |
| County: | Etowah |
| Place of Formation: | Etowah County |
| Registered Office Street Address: | 1250 ALABAMA HWY 77SOUTHSIDE, AL 35907 |
| Registered Office Street Address ZIP Code: | 35907 |
| Authorized Capital: | 100 @ $1 PV |
Activities
ENGAGE IN PHARMACEUTICAL
RETAIL
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1396753927 | 2006-08-03 | 2021-01-14 | 1250 HIGHWAY 77, SOUTHSIDE, AL, 359070405, US | 1250 HIGHWAY 77, SOUTHSIDE, AL, 359070405, US | |||||||||||||||||||||||||||||||||
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| Phone | +1 256-413-4473 |
| Fax | 2564137358 |
Authorized person
| Name | TRACY BOGGS |
| Role | OWNER |
| Phone | 2564134473 |
Taxonomy
| Taxonomy Code | 333600000X - Pharmacy |
| Is Primary | No |
| Taxonomy Code | 3336C0003X - Community/Retail Pharmacy |
| License Number | 112170 |
| State | AL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 142548 |
| State | AL |
| Issuer | PK |
| Number | 2137549 |
| Plan Name | Plan Year | EIN/PN | Received | Sponsor | Total number of participants | |||||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| SOUTHSIDE FAMILY PHARMACY (WELFARE PLAN) | 2022 | 460633514 | 2023-07-27 | SOUTHSIDE FAMILY PHARMACY | 6 | |||||||||||||||||||||||||||||||||||||
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| Administrator’s EIN | 472506773 |
| Plan administrator’s name | KENNION & CO, LLC |
| Plan administrator’s address | 2828 OLD 280 COURT, SUITE 110, VESTAVIA, AL, 35243 |
| Administrator’s telephone number | 8669665457 |
Signature of
| Role | Plan administrator |
| Date | 2023-07-19 |
| Name of individual signing | W. HAL SHEPHERD |
| Role | Employer/plan sponsor |
| Date | 2023-07-19 |
| Name of individual signing | W. HAL SHEPHERD |
| File | View Page |
| Three-digit plan number (PN) | 951 |
| Effective date of plan | 2020-10-01 |
| Business code | 446110 |
| Sponsor’s telephone number | 8669665457 |
| Plan sponsor’s address | 1250 HWY 77, SOUTHSIDE, AL, 35907 |
Plan administrator’s name and address
| Administrator’s EIN | 472506773 |
| Plan administrator’s name | KENNION & CO, LLC |
| Plan administrator’s address | 2828 OLD 280 COURT, SUITE 110, VESTAVIA, AL, 35243 |
| Administrator’s telephone number | 8669665457 |
Signature of
| Role | Plan administrator |
| Date | 2022-07-20 |
| Name of individual signing | W. HAL SHEPHERD |
| Role | Employer/plan sponsor |
| Date | 2022-07-20 |
| Name of individual signing | W. HAL SHEPHERD |
| File | View Page |
| Three-digit plan number (PN) | 951 |
| Effective date of plan | 2020-10-01 |
| Business code | 446110 |
| Sponsor’s telephone number | 8669665457 |
| Plan sponsor’s address | 1250 HWY 77, SOUTHSIDE, AL, 35907 |
Plan administrator’s name and address
| Administrator’s EIN | 472506773 |
| Plan administrator’s name | KENNION & CO, LLC |
| Plan administrator’s address | 2828 OLD 280 COURT, SUITE 110, VESTAVIA, AL, 35243 |
| Administrator’s telephone number | 8669665457 |
Signature of
| Role | Plan administrator |
| Date | 2021-07-23 |
| Name of individual signing | W. HAL SHEPHERD |
| Role | Employer/plan sponsor |
| Date | 2021-07-23 |
| Name of individual signing | W. HAL SHEPHERD |
| Name | Role | Address |
|---|---|---|
| BOGGS, TRACY L | Agent | 275 MORNING GLORY CIRCLETALLADEGA, AL 35160 |
| Name | Role | Address |
|---|---|---|
| BOGGS, TRACY L | Director | 275 MORNING GLORY CIRCLETALLADEGA, AL 35160 |
| BOGGS, SARA H | Director | 275 MORNING GLORY CIRCLETALLADEGA, AL 35160 |
| Name | Role | Address |
|---|---|---|
| BOGGS, TRACY L | Incorporator | 275 MORNING GLORY CIRCLETALLADEGA, AL 35160 |
Date of last update: 31 Jul 2024
Sources: Alabama Secretary of State
