Provider Demographics
NPI:1730903113
Name:SOUTHERN SPECIALTY CLINIC, LLC
Entity type:Organization
Organization Name:SOUTHERN SPECIALTY CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:SHARON
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:PENNINGTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:601-985-8296
Mailing Address - Street 1:122 WOODLANDS GLEN CIR
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:MS
Mailing Address - Zip Code:39047-7107
Mailing Address - Country:US
Mailing Address - Phone:601-985-8296
Mailing Address - Fax:
Practice Address - Street 1:803 LIBERTY RD
Practice Address - Street 2:
Practice Address - City:FLOWOOD
Practice Address - State:MS
Practice Address - Zip Code:39232-9000
Practice Address - Country:US
Practice Address - Phone:601-714-1967
Practice Address - Fax:601-714-1966
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOUTHERN SPECIALTY CLINIC, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-11-12
Last Update Date:2024-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy