Provider Demographics
NPI:1497081178
Name:SOUTHWORTH, JASON (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:
Last Name:SOUTHWORTH
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4102 BEN FRANKLIN BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27704-2140
Mailing Address - Country:US
Mailing Address - Phone:919-972-7719
Mailing Address - Fax:919-972-7721
Practice Address - Street 1:4102 BEN FRANKLIN BLVD
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27704
Practice Address - Country:US
Practice Address - Phone:919-972-7719
Practice Address - Fax:919-972-7721
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-30
Last Update Date:2021-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC13903183500000X
NC146733336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No183500000XPharmacy Service ProvidersPharmacist