MEDICARE: SOUTHERN PHARMACY SERVICES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3336L0003X	Long Term Care Pharmacy	6171	LA
2	332B00000X	Durable Medical Equipment & Medical Supplies	6171	LA
3	3336C0004X	Compounding Pharmacy	6171	LA
4	3336C0003X	Community/Retail Pharmacy

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	5DK78	OTHER	LA	MEDICARE PTAN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1073742722
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHERN PHARMACY SERVICES

Provider Business Mailing Address
First Line	:	704 N PARKERSON AVE
Second Line	:
City	:	CROWLEY
State	:	LA
Zip	:	70526-4355
Country	:	US
Telephone Number	:	337-783-9084
Fax Number	:	337-783-9085

Provider Business Practice Location Address
First Line	:	704 N PARKERSON AVE
Second Line	:
City	:	CROWLEY
State	:	LA
Zip	:	70526-4355
Country	:	US
Telephone Number	:	337-783-9084
Fax Number	:	337-783-9085

Authorized Official
Title or Position	:	OWNER/PHARMACIST
Name	:	BRANDY FREED
Credential	:
Telephone Number	:	337-783-9084

Provider Enumeration Date	:	07/02/2009
Last Update Date	:	08/18/2016

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Practice Location Address:

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Directions to “SOUTHERN PHARMACY SERVICES ” Practice Location

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