Healthcare Provider Details

I. General information

NPI: 1750665584
Provider Name (Legal Business Name): SOUTHERN PAIN INSTITUTE P C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/28/2011
Last Update Date: 03/20/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1975 HIGHWAY 54 W STE 100
FAYETTEVILLE GA
30214-4794
US

IV. Provider business mailing address

1975 HIGHWAY 54 W SUITE 100
FAYETTEVILLE GA
30214-4794
US

V. Phone/Fax

Practice location:
  • Phone: 770-631-5158
  • Fax: 770-632-3731
Mailing address:
  • Phone: 770-631-5158
  • Fax: 404-591-7959

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPHRE009784
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: LYNN CLAVO
Title or Position: CHIEF PHARMACIST
Credential:
Phone: 770-313-3380