MEDICARE: SOUTHERN VILLAGE 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	11405	NC

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	2138555	OTHER		PK

General Provider Information

NPI Number	:	1033456371
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHERN VILLAGE PHARMACY INC

Provider Business Mailing Address
First Line	:	300 MARKET ST
Second Line	:	SUITE 114
City	:	CHAPEL HILL
State	:	NC
Zip	:	27516-4493
Country	:	US
Telephone Number	:	919-240-4084
Fax Number	:	919-724-4568

Provider Business Practice Location Address
First Line	:	300 MARKET ST
Second Line	:	SUITE 114
City	:	CHAPEL HILL
State	:	NC
Zip	:	27516-4493
Country	:	US
Telephone Number	:	919-240-4084
Fax Number	:	919-724-4568

Authorized Official
Title or Position	:	OWNER/MANAGER
Name	:	EDWARD GAETON LEAKE
Credential	:
Telephone Number	:	919-240-4084

Provider Enumeration Date	:	01/07/2013
Last Update Date	:	01/21/2025

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Directions to “SOUTHERN VILLAGE PHARMACY INC ” Practice Location

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