Healthcare Provider Details

I. General information

NPI: 1285614057
Provider Name (Legal Business Name): JOEL LYNN SOUTHERLAND R.PH.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/18/2006
Last Update Date: 01/14/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

538 LONE OAK RD
PADUCAH KY
42003-4538
US

IV. Provider business mailing address

1525 STATE ROUTE 2151
MELBER KY
42069-8933
US

V. Phone/Fax

Practice location:
  • Phone: 270-443-3311
  • Fax: 270-442-7710
Mailing address:
  • Phone: 270-674-5697
  • Fax: 270-674-6097

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number9491
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: