Provider Demographics
NPI:1467058248
Name:SOUTHERN, SHERRY LYNN
Entity Type:Individual
Prefix:
First Name:SHERRY
Middle Name:LYNN
Last Name:SOUTHERN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 S KY HIGHWAY 15
Mailing Address - Street 2:
Mailing Address - City:HAZARD
Mailing Address - State:KY
Mailing Address - Zip Code:41701-6029
Mailing Address - Country:US
Mailing Address - Phone:606-436-3128
Mailing Address - Fax:606-435-0664
Practice Address - Street 1:30 S KY HIGHWAY 15
Practice Address - Street 2:
Practice Address - City:HAZARD
Practice Address - State:KY
Practice Address - Zip Code:41701-6029
Practice Address - Country:US
Practice Address - Phone:606-436-3128
Practice Address - Fax:606-435-0664
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-08
Last Update Date:2020-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY009749183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist