Provider Demographics
NPI:1619215381
Name:SOUTHERN CANCER CENTER P C
Entity Type:Organization
Organization Name:SOUTHERN CANCER CENTER P C
Other - Org Name:COASTAL PHARMACY LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LAUREN
Authorized Official - Middle Name:
Authorized Official - Last Name:PETTIS
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:251-625-6896
Mailing Address - Street 1:29653 ANCHOR CROSS BLVD
Mailing Address - Street 2:SUTIE A 101
Mailing Address - City:DAPHNE
Mailing Address - State:AL
Mailing Address - Zip Code:36526-9594
Mailing Address - Country:US
Mailing Address - Phone:251-607-5061
Mailing Address - Fax:251-607-5062
Practice Address - Street 1:29653 ANCHOR CROSS BLVD
Practice Address - Street 2:SUTIE A 101
Practice Address - City:DAPHNE
Practice Address - State:AL
Practice Address - Zip Code:36526-9594
Practice Address - Country:US
Practice Address - Phone:251-607-5061
Practice Address - Fax:251-607-5062
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-30
Last Update Date:2023-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
0138455OtherNCPDP PROVIDER IDENTIFICATION NUMBER
0138455OtherNCPDP PROVIDER IDENTIFICATION NUMBER