Provider Demographics
NPI:1013558469
Name:SOUTHERN, STEPHEN PAUL (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:PAUL
Last Name:SOUTHERN
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 HORSEY AVE
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:DE
Mailing Address - Zip Code:19956-1211
Mailing Address - Country:US
Mailing Address - Phone:410-739-8669
Mailing Address - Fax:
Practice Address - Street 1:38627 BENRO DR
Practice Address - Street 2:
Practice Address - City:DELMAR
Practice Address - State:DE
Practice Address - Zip Code:19940-3572
Practice Address - Country:US
Practice Address - Phone:302-907-1010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-07
Last Update Date:2019-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEA1-0005454183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist