Provider Demographics
NPI:1073742722
Name:SOUTHERN PHARMACY SERVICES
Entity Type:Organization
Organization Name:SOUTHERN PHARMACY SERVICES
Other - Org Name:MEDICINE SHOPPE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:BRANDY
Authorized Official - Middle Name:
Authorized Official - Last Name:FREED
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:337-783-9084
Mailing Address - Street 1:704 N PARKERSON AVE
Mailing Address - Street 2:
Mailing Address - City:CROWLEY
Mailing Address - State:LA
Mailing Address - Zip Code:70526-4355
Mailing Address - Country:US
Mailing Address - Phone:337-783-9084
Mailing Address - Fax:337-783-9085
Practice Address - Street 1:704 N PARKERSON AVE
Practice Address - Street 2:
Practice Address - City:CROWLEY
Practice Address - State:LA
Practice Address - Zip Code:70526-4355
Practice Address - Country:US
Practice Address - Phone:337-783-9084
Practice Address - Fax:337-783-9085
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-02
Last Update Date:2016-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA6171332B00000X, 3336C0004X, 3336L0003X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1235253Medicaid
LA5DK78OtherMEDICARE PTAN
LA5DK78OtherMEDICARE PTAN