Healthcare Provider Details

I. General information

NPI: 1548515620
Provider Name (Legal Business Name): SOUTHERN RX LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/16/2012
Last Update Date: 07/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10131 W COMMERCIAL BLVD
SUNRISE FL
33351-4327
US

IV. Provider business mailing address

10131 W COMMERCIAL BLVD
SUNRISE FL
33351-4327
US

V. Phone/Fax

Practice location:
  • Phone: 954-722-8111
  • Fax: 954-722-8222
Mailing address:
  • Phone: 954-722-8111
  • Fax: 954-722-8222

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: MR. JONATHAN ALAN MORDIS
Title or Position: PHARMACIST IN CHARGE
Credential: PHARM D
Phone: 954-298-1736