Provider Demographics
NPI:1033271044
Name:SOUTHERN, SCARLET DANIELLE (RPH)
Entity Type:Individual
Prefix:
First Name:SCARLET
Middle Name:DANIELLE
Last Name:SOUTHERN
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:924 AVENIDA MANANA NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87110-6167
Mailing Address - Country:US
Mailing Address - Phone:505-681-9780
Mailing Address - Fax:
Practice Address - Street 1:INTERSTATE 40, EXIT 102
Practice Address - Street 2:
Practice Address - City:SAN FIDEL
Practice Address - State:NM
Practice Address - Zip Code:87049
Practice Address - Country:US
Practice Address - Phone:505-552-5394
Practice Address - Fax:505-552-5464
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC118331835P1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy