Provider Demographics
NPI:1417119157
Name:SOUTHALL PHARMACY PLLC
Entity Type:Organization
Organization Name:SOUTHALL PHARMACY PLLC
Other - Org Name:EXTENCARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:FRANCIS
Authorized Official - Middle Name:W
Authorized Official - Last Name:SOUTHALL
Authorized Official - Suffix:JR
Authorized Official - Credentials:RPH
Authorized Official - Phone:270-692-3111
Mailing Address - Street 1:110 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:KY
Mailing Address - Zip Code:40033-1235
Mailing Address - Country:US
Mailing Address - Phone:270-699-9251
Mailing Address - Fax:
Practice Address - Street 1:110 E MAIN ST
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:KY
Practice Address - Zip Code:40033-1235
Practice Address - Country:US
Practice Address - Phone:270-699-9251
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-25
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYP07263332B00000X, 332BN1400X, 3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BN1400XSuppliersDurable Medical Equipment & Medical SuppliesNursing Facility Supplies