Provider Demographics
NPI:1063505428
Name:SOUTHERN FAMILY MARKETS LLC
Entity Type:Organization
Organization Name:SOUTHERN FAMILY MARKETS LLC
Other - Org Name:SOUTHERN FAMILY MARKET
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF PHARMACY
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:TOW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:205-912-4234
Mailing Address - Street 1:PO BOX 8500
Mailing Address - Street 2:LOCKBOX 8531
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19178-8531
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:823 N HOUSTON RD
Practice Address - Street 2:
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31093-1501
Practice Address - Country:US
Practice Address - Phone:478-929-5323
Practice Address - Fax:478-328-3123
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-30
Last Update Date:2009-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
GAPHRE0084683336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1153484OtherNCPDP PROVIDER IDENTIFICATION NUMBER
GA950825064CMedicaid
GA950825064CMedicaid