Provider Demographics
NPI:1003465451
Name:SOUTHALL, PATRICK J (RPH)
Entity type:Individual
Prefix:
First Name:PATRICK
Middle Name:J
Last Name:SOUTHALL
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1250 PATROL RD
Mailing Address - Street 2:
Mailing Address - City:CHARLESTOWN
Mailing Address - State:IN
Mailing Address - Zip Code:47111-8670
Mailing Address - Country:US
Mailing Address - Phone:812-406-2299
Mailing Address - Fax:
Practice Address - Street 1:1250 PATROL RD
Practice Address - Street 2:
Practice Address - City:CHARLESTOWN
Practice Address - State:IN
Practice Address - Zip Code:47111-8670
Practice Address - Country:US
Practice Address - Phone:812-406-2299
Practice Address - Fax:812-406-2299
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-09
Last Update Date:2019-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY102781835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist