Provider Demographics
NPI:1316002074
Name:SOUTHERLAND, JULIAN (RPH)
Entity Type:Individual
Prefix:
First Name:JULIAN
Middle Name:
Last Name:SOUTHERLAND
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:996 E STORM CLOUD DR
Mailing Address - Street 2:
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86409-1103
Mailing Address - Country:US
Mailing Address - Phone:928-757-9734
Mailing Address - Fax:928-692-4141
Practice Address - Street 1:3269 STOCKTON HILL RD
Practice Address - Street 2:
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86409-3619
Practice Address - Country:US
Practice Address - Phone:928-757-0618
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ10406183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist