Provider Demographics
NPI:1962703165
Name:SOUTHALL, JARRETT WILSON (RPH)
Entity type:Individual
Prefix:MR
First Name:JARRETT
Middle Name:WILSON
Last Name:SOUTHALL
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 1:1518 HICKORY ROCK RD
Mailing Address - Street 2:
Mailing Address - City:LOUISBURG
Mailing Address - State:NC
Mailing Address - Zip Code:27549-8187
Mailing Address - Country:US
Mailing Address - Phone:919-497-0156
Mailing Address - Fax:
Practice Address - Street 1:1518 HICKORY ROCK RD
Practice Address - Street 2:
Practice Address - City:LOUISBURG
Practice Address - State:NC
Practice Address - Zip Code:27549-8187
Practice Address - Country:US
Practice Address - Phone:919-497-0156
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-04
Last Update Date:2010-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC12267183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist