Provider Demographics
NPI:1962282178
Name:SOUTHERN CANCER CENTER, PC
Entity type:Organization
Organization Name:SOUTHERN CANCER CENTER, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LAUREN
Authorized Official - Middle Name:
Authorized Official - Last Name:PETTIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:251-625-6896
Mailing Address - Street 1:SOUTHERN CANCER CENTER, PC DBA COASTAL PHARM PROVIDENCE
Mailing Address - Street 2:29653 ANCHOR CROSS BLVD.
Mailing Address - City:DAPHNE
Mailing Address - State:AL
Mailing Address - Zip Code:36526-9594
Mailing Address - Country:US
Mailing Address - Phone:251-607-5061
Mailing Address - Fax:
Practice Address - Street 1:6701 AIRPORT BLVD.
Practice Address - Street 2:'B' BLDG., 'T' LEVEL
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36608-3764
Practice Address - Country:US
Practice Address - Phone:251-607-5061
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-04
Last Update Date:2023-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy