Provider Demographics
NPI:1285614057
Name:SOUTHERLAND, JOEL LYNN (RPH)
Entity type:Individual
Prefix:
First Name:JOEL
Middle Name:LYNN
Last Name:SOUTHERLAND
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1525 STATE ROUTE 2151
Mailing Address - Street 2:
Mailing Address - City:MELBER
Mailing Address - State:KY
Mailing Address - Zip Code:42069-8933
Mailing Address - Country:US
Mailing Address - Phone:270-674-5697
Mailing Address - Fax:270-674-6097
Practice Address - Street 1:538 LONE OAK RD
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42003-4538
Practice Address - Country:US
Practice Address - Phone:270-443-3311
Practice Address - Fax:270-442-7710
Is Sole Proprietor?:No
Enumeration Date:2006-01-18
Last Update Date:2009-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY9491183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist