Healthcare Provider Details

I. General information

NPI: 1730903113
Provider Name (Legal Business Name): SOUTHERN SPECIALTY CLINIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/12/2024
Last Update Date: 11/12/2024
Certification Date: 11/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

803 LIBERTY RD
FLOWOOD MS
39232-9000
US

IV. Provider business mailing address

122 WOODLANDS GLEN CIR
BRANDON MS
39047-7107
US

V. Phone/Fax

Practice location:
  • Phone: 601-714-1967
  • Fax: 601-714-1966
Mailing address:
  • Phone: 601-985-8296
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State

VIII. Authorized Official

Name: DR. SHARON MARIE PENNINGTON
Title or Position: CHIEF EXECUTIVE OFFICER
Credential: MD
Phone: 601-985-8296