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General NPI Number Information
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NPI Number | 1750665584
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Entity Type | Organization
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Legal Business Name | SOUTHERN PAIN INSTITUTE P C
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Dates
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Enumeration Date | 09/28/2011
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Last Update Date | 03/20/2013
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Provider Practice Location Address
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Address Line | 1975 HIGHWAY 54 W STE 100
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City | FAYETTEVILLE
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State | GA
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Zip | 30214-4794
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Country | US
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Telephone | 770-631-5158
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Fax | 770-632-3731
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Provider Business Mailing Address
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Address Line | 1975 HIGHWAY 54 W SUITE 100
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City | FAYETTEVILLE
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State | GA
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Zip | 30214-4794
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Country | US
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Telephone | 770-631-5158
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Fax | 404-591-7959
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Authorized Official
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Title or Position | CHIEF PHARMACIST
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Name | LYNN CLAVO
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Credential |
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Telephone | 770-313-3380
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3336C0004X
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Taxonomy Name | Compounding Pharmacy
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 333600000X
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Taxonomy Name | Pharmacy
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number | PHRE009784
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License Number State | GA
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