Provider Demographics
NPI:1902483712
Name:SOUTHERN PHARMACARE LLC
Entity Type:Organization
Organization Name:SOUTHERN PHARMACARE 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:PHARM D
Authorized Official - Phone:912-705-7790
Mailing Address - Street 1:711 LAMBERT BENNETT RD
Mailing Address - Street 2:
Mailing Address - City:JESUP
Mailing Address - State:GA
Mailing Address - Zip Code:31546-1550
Mailing Address - Country:US
Mailing Address - Phone:912-705-7790
Mailing Address - Fax:912-559-2597
Practice Address - Street 1:755 S MAIN ST
Practice Address - Street 2:
Practice Address - City:BAXLEY
Practice Address - State:GA
Practice Address - Zip Code:31513-0130
Practice Address - Country:US
Practice Address - Phone:912-294-1684
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-26
Last Update Date:2021-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy