1578659629 NPI number — SOUTHERN PHARMACEUTICAL CORPORATION

Table of content: (NPI 1578659629)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578659629 NPI number — SOUTHERN PHARMACEUTICAL CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHERN PHARMACEUTICAL CORPORATION
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1578659629
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/16/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1019 TOWN DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HIGHLAND HEIGHTS
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
41076-9114
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
859-441-8876
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
338 HIGHWAY 12 W STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KOSCIUSKO
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39090
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
662-285-4531
Provider Business Practice Location Address Fax Number:
662-285-5661
Provider Enumeration Date:
10/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CRAWFORD
Authorized Official First Name:
GREGORY
Authorized Official Middle Name:
J
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
859-441-8876

Provider Taxonomy Codes

  • Taxonomy code: 332BX2000X , with the licence number:  08076/11.1 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 01522320 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




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