Provider Demographics
NPI:1154414522
Name:SOUTHERN FAMILY MARKETS LLC
Entity type:Organization
Organization Name:SOUTHERN FAMILY MARKETS LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
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 1:1906 SHADY BROOK ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:TN
Mailing Address - Zip Code:38401-3989
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1906 SHADY BROOK ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:TN
Practice Address - Zip Code:38401-3989
Practice Address - Country:US
Practice Address - Phone:931-388-4793
Practice Address - Fax:931-388-4798
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
TN0000001568333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered333600000XSuppliersPharmacy
Not Answered3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
4438900OtherOTHER ID NUMBER-COMMERCIAL NUMBER
TN4438900Medicaid
5562170035Medicare ID - Type Unspecified