Provider Demographics
NPI:1336232701
Name:SOUTHERN FAMILY MARKETS LLC
Entity Type:Organization
Organization Name:SOUTHERN FAMILY MARKETS LLC
Other - Org Name:SOUTHERN FAMILY MARKET
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF PHARMACY
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:TOW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:205-912-4234
Mailing Address - Street 1:1050 ALAMANCE CHURCH RD
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27406-3808
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1050 ALAMANCE CHURCH RD
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27406-3808
Practice Address - Country:US
Practice Address - Phone:336-378-0830
Practice Address - Fax:336-335-3027
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC09187333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered333600000XSuppliersPharmacy
Not Answered3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0418222Medicaid
3404530OtherOTHER ID NUMBER-COMMERCIAL NUMBER
NC0418222Medicaid