1790878163 NPI number — SOUTHERN FAMILY MARKETS LLC

Table of content: (NPI 1790878163)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790878163 NPI number — SOUTHERN FAMILY MARKETS LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHERN FAMILY MARKETS LLC
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:
6
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:
1790878163
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/30/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 8500
Provider Second Line Business Mailing Address:
LOCKBOX 8531
Provider Business Mailing Address City Name:
PHILADELPHIA
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19178-8531
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2934 N HILLS ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MERIDIAN
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39305-2645
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-693-3681
Provider Business Practice Location Address Fax Number:
601-693-1742
Provider Enumeration Date:
09/30/2006

Additional Information

Authorized Official

Authorized Official Last Name:
TOW
Authorized Official First Name:
MARK
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF PHARMACY
Authorized Official Telephone Number:
205-912-4234

Provider Taxonomy Codes

  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 04979/01.2 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2586216 . This is a "NCPDP PROVIDER IDENTIFICATION NUMBER" identifier . This identifiers is of the category "OTHER".
  • Identifier: 00330600 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




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