=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790444156
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FRANCIS W SOUTHALL JR
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/14/2021
-----------------------------------------------------
Last Update Date | 12/14/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 325 W WALNUT ST STE 500
-----------------------------------------------------
City | LEBANON
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40033-1379
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-692-3111
-----------------------------------------------------
Fax | 270-692-4211
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 325 W WALNUT ST STE 500
-----------------------------------------------------
City | LEBANON
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40033-1379
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-692-3111
-----------------------------------------------------
Fax | 270-692-4211
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | FRANCIS W SOUTHALL, JR
-----------------------------------------------------
Credential | RPH
-----------------------------------------------------
Telephone | 270-692-3111
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336L0003X
-----------------------------------------------------
Taxonomy Name | Long Term Care Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------