Provider Demographics
NPI:1720069628
Name:CHOICE SOURCE THERAPEUTIC SOUTH LLC
Entity Type:Organization
Organization Name:CHOICE SOURCE THERAPEUTIC SOUTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED SIGNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:BORDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:800-225-5967
Mailing Address - Street 1:DEPARTMENT 6175
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90088-6175
Mailing Address - Country:US
Mailing Address - Phone:800-225-5967
Mailing Address - Fax:909-799-4364
Practice Address - Street 1:1048 STANTON RD
Practice Address - Street 2:SUITE A
Practice Address - City:DAPHNE
Practice Address - State:AL
Practice Address - Zip Code:36526-4294
Practice Address - Country:US
Practice Address - Phone:251-621-5300
Practice Address - Fax:251-621-5318
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-08
Last Update Date:2007-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL112079332B00000X, 333600000X
3336S0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336S0011XSuppliersPharmacySpecialty Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0330543Medicaid
AL5535140001Medicare NSC