Provider Demographics
NPI:1497871859
Name:SOUTHALL PHARMACY PLLC
Entity Type:Organization
Organization Name:SOUTHALL PHARMACY PLLC
Other - Org Name:
Other - Org Type:
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 1:325 W WALNUT ST
Mailing Address - Street 2:SUITE 500
Mailing Address - City:LEBANON
Mailing Address - State:KY
Mailing Address - Zip Code:40033-1377
Mailing Address - Country:US
Mailing Address - Phone:270-692-3111
Mailing Address - Fax:270-692-4211
Practice Address - Street 1:325 W WALNUT ST
Practice Address - Street 2:SUITE 500
Practice Address - City:LEBANON
Practice Address - State:KY
Practice Address - Zip Code:40033-1377
Practice Address - Country:US
Practice Address - Phone:270-692-3111
Practice Address - Fax:270-692-4211
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-21
Last Update Date:2009-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYP02451332B00000X, 332BD1200X, 332BN1400X, 332BP3500X, 332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BD1200XSuppliersDurable Medical Equipment & Medical SuppliesDialysis Equipment & Supplies
No332BN1400XSuppliersDurable Medical Equipment & Medical SuppliesNursing Facility Supplies
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
No332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY90040783Medicaid
KY90040783Medicaid