Healthcare Provider Details

I. General information

NPI: 1154922441
Provider Name (Legal Business Name): SOUTHERN PHARMACY GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/04/2020
Last Update Date: 11/04/2020
Certification Date: 11/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 ALLISON ST.
JESUP GA
31545
US

IV. Provider business mailing address

711 LAMBERT BENNETT RD
JESUP GA
31546
US

V. Phone/Fax

Practice location:
  • Phone: 912-559-2961
  • Fax: 912-559-2597
Mailing address:
  • Phone: 912-294-1684
  • Fax: 912-559-2597

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: TRAVIS RAY HARRISON
Title or Position: OWNER
Credential: PHARMD
Phone: 912-294-1684