Provider Demographics
NPI:1093205346
Name:SOUTHLAND PHARMACY LLC
Entity Type:Organization
Organization Name:SOUTHLAND PHARMACY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:TERRI
Authorized Official - Middle Name:
Authorized Official - Last Name:SCIOSCIA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:931-563-0008
Mailing Address - Street 1:482 INTERSTATE DR
Mailing Address - Street 2:SUITE K
Mailing Address - City:MANCHESTER
Mailing Address - State:TN
Mailing Address - Zip Code:37355-3485
Mailing Address - Country:US
Mailing Address - Phone:931-563-0008
Mailing Address - Fax:931-954-0524
Practice Address - Street 1:482 INTERSTATE DR STE K
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:TN
Practice Address - Zip Code:37355
Practice Address - Country:US
Practice Address - Phone:615-788-5998
Practice Address - Fax:931-954-0524
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-12
Last Update Date:2018-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336M0002X
TN62983336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336M0002XSuppliersPharmacyMail Order Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2177446OtherPK
TNQ036024Medicaid