Healthcare Provider Details

I. General information

NPI: 1073742722
Provider Name (Legal Business Name): SOUTHERN PHARMACY SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/02/2009
Last Update Date: 08/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

704 N PARKERSON AVE
CROWLEY LA
70526-4355
US

IV. Provider business mailing address

704 N PARKERSON AVE
CROWLEY LA
70526-4355
US

V. Phone/Fax

Practice location:
  • Phone: 337-783-9084
  • Fax: 337-783-9085
Mailing address:
  • Phone: 337-783-9084
  • Fax: 337-783-9085

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number6171
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number6171
License Number StateLA
# 4
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number6171
License Number StateLA

VIII. Authorized Official

Name: BRANDY FREED
Title or Position: OWNER/PHARMACIST
Credential:
Phone: 337-783-9084