MEDICARE: MICHAEL SOUTHALL

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	183500000X	Pharmacist	019560	KY

General Provider Information

NPI Number	:	1609465152
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAEL SOUTHALL

Provider Business Mailing Address
First Line	:	325 W WALNUT ST STE 500
Second Line	:
City	:	LEBANON
State	:	KY
Zip	:	40033-1379
Country	:	US
Telephone Number	:	270-692-3111
Fax Number	:

Provider Business Practice Location Address
First Line	:	325 W WALNUT ST STE 500
Second Line	:
City	:	LEBANON
State	:	KY
Zip	:	40033-1379
Country	:	US
Telephone Number	:	270-692-3111
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/11/2021
Last Update Date	:	01/11/2021

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Directions to “ MICHAEL SOUTHALL ” Practice Location

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