Provider Demographics
NPI:1699045971
Name:SOUTHERN ADVENTURES
Entity Type:Organization
Organization Name:SOUTHERN ADVENTURES
Other - Org Name:THE MEDICINE SHOPPE 1975
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:BERCIS
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:814-333-1121
Mailing Address - Street 1:16332 CONNEAUT LAKE RD
Mailing Address - Street 2:
Mailing Address - City:MEADVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:16335-3843
Mailing Address - Country:US
Mailing Address - Phone:814-333-1121
Mailing Address - Fax:814-337-7990
Practice Address - Street 1:16332 CONNEAUT LAKE RD
Practice Address - Street 2:
Practice Address - City:MEADVILLE
Practice Address - State:PA
Practice Address - Zip Code:16335-3843
Practice Address - Country:US
Practice Address - Phone:814-333-1121
Practice Address - Fax:814-337-7990
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-04
Last Update Date:2016-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPP482201333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy