Provider Demographics
NPI:1720301054
Name:SOUTHERN HEMOPHILIA INFUSION
Entity Type:Organization
Organization Name:SOUTHERN HEMOPHILIA INFUSION
Other - Org Name:SOUTHERN HEMOPHILIA INFUSION PHARMACY, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:KELLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:251-937-8792
Mailing Address - Street 1:154 HAND AVE
Mailing Address - Street 2:
Mailing Address - City:BAY MINETTE
Mailing Address - State:AL
Mailing Address - Zip Code:36507-4825
Mailing Address - Country:US
Mailing Address - Phone:251-937-8792
Mailing Address - Fax:251-937-8793
Practice Address - Street 1:154 HAND AVE
Practice Address - Street 2:
Practice Address - City:BAY MINETTE
Practice Address - State:AL
Practice Address - Zip Code:36507-4825
Practice Address - Country:US
Practice Address - Phone:251-937-8792
Practice Address - Fax:251-937-8793
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-01
Last Update Date:2011-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336H0001X
AL1133703336S0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336S0011XSuppliersPharmacySpecialty Pharmacy
No3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
0136413OtherNCPDP PROVIDER IDENTIFICATION NUMBER