Basic Information
| Provider Information | |||||||||
| NPI: | 1316002074 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SOUTHERLAND | ||||||||
| FirstName: | JULIAN | ||||||||
| MiddleName: | |||||||||
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| Credential: | RPH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 996 E STORM CLOUD DR | ||||||||
| Address2: | |||||||||
| City: | KINGMAN | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 864091103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9287579734 | ||||||||
| FaxNumber: | 9286924141 | ||||||||
| Practice Location | |||||||||
| Address1: | 3269 STOCKTON HILL RD | ||||||||
| Address2: | |||||||||
| City: | KINGMAN | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 864093619 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9287570618 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/23/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | 10406 | AZ | Y | Pharmacy Service Providers | Pharmacist |
No ID Information.