Healthcare Provider Details

I. General information

NPI: 1962282178
Provider Name (Legal Business Name): SOUTHERN CANCER CENTER, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/04/2023
Last Update Date: 10/04/2023
Certification Date: 10/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6701 AIRPORT BLVD. 'B' BLDG., 'T' LEVEL
MOBILE AL
36608-3764
US

IV. Provider business mailing address

SOUTHERN CANCER CENTER, PC DBA COASTAL PHARM PROVIDENCE 29653 ANCHOR CROSS BLVD.
DAPHNE AL
36526-9594
US

V. Phone/Fax

Practice location:
  • Phone: 251-607-5061
  • Fax:
Mailing address:
  • Phone: 251-607-5061
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: LAUREN PETTIS
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 251-625-6896