1104938992 NPI number — SOUTHERN PHARMACEUTICAL CORPORATION

Table of content: (NPI 1104938992)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104938992 NPI number — SOUTHERN PHARMACEUTICAL CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHERN PHARMACEUTICAL CORPORATION
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104938992
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/25/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1019 TOWN DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HIGHLAND HEIGHTS
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
41076-9114
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
859-441-8876
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
165 ROSECREST DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COLUMBUS
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39701-5501
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
662-327-2060
Provider Business Practice Location Address Fax Number:
662-327-6659
Provider Enumeration Date:
08/31/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CRAWFORD
Authorized Official First Name:
GREGORY
Authorized Official Middle Name:
J
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
859-441-8876

Provider Taxonomy Codes

  • Taxonomy code: 332BX2000X , with the licence number:  02591 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 333600000X , with the licence number: 02591 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336C0003X , with the licence number: 02776 01 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0004X , with the licence number: 02776 02 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336H0001X , with the licence number: 02776 02.0 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336M0002X , with the licence number: 02591 06 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336M0002X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336S0011X , with the licence number: 02776 02 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0112328-01 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 129260407 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1455025 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0126941 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 04285815 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 009412720 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0173528-01 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1992721 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200059890A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 54031018 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 11531 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00040398 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 128104716 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200041370A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4581848 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 90012436 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0298324 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200059890B , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".




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