=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578659629
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUTHERN PHARMACEUTICAL CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/05/2006
-----------------------------------------------------
Last Update Date | 09/16/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 338 HIGHWAY 12 W STE A
-----------------------------------------------------
City | KOSCIUSKO
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39090
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-285-4531
-----------------------------------------------------
Fax | 662-285-5661
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1019 TOWN DR
-----------------------------------------------------
City | HIGHLAND HEIGHTS
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 41076-9114
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 859-441-8876
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | GREGORY J CRAWFORD
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 859-441-8876
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332BX2000X
-----------------------------------------------------
Taxonomy Name | Oxygen Equipment & Supplies (DME)
-----------------------------------------------------
License Number | 08076/11.1
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------