Provider Demographics
NPI:1154922441
Name:SOUTHERN PHARMACY GROUP LLC
Entity type:Organization
Organization Name:SOUTHERN PHARMACY GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TRAVIS
Authorized Official - Middle Name:RAY
Authorized Official - Last Name:HARRISON
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:912-294-1684
Mailing Address - Street 1:711 LAMBERT BENNETT RD
Mailing Address - Street 2:
Mailing Address - City:JESUP
Mailing Address - State:GA
Mailing Address - Zip Code:31546
Mailing Address - Country:US
Mailing Address - Phone:912-294-1684
Mailing Address - Fax:912-559-2597
Practice Address - Street 1:110 ALLISON ST.
Practice Address - Street 2:
Practice Address - City:JESUP
Practice Address - State:GA
Practice Address - Zip Code:31545
Practice Address - Country:US
Practice Address - Phone:912-559-2961
Practice Address - Fax:912-559-2597
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-04
Last Update Date:2020-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy