1396189767 NPI number — SOUTHEAST HEALTH PHARMACY LLC

Table of content: (NPI 1396189767)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396189767 NPI number — SOUTHEAST HEALTH PHARMACY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHEAST HEALTH PHARMACY LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
SOUTHEASTHEALTH PHARMACY
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1396189767
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/03/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 989
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
POPLAR BLUFF
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63902-0989
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
573-778-1608
Provider Business Mailing Address Fax Number:
573-778-1645

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2002 KANELL BLVD
Provider Second Line Business Practice Location Address:
STE 102
Provider Business Practice Location Address City Name:
POPLAR BLUFF
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63901-4045
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-778-1608
Provider Business Practice Location Address Fax Number:
573-778-1645
Provider Enumeration Date:
04/29/2013

Additional Information

Authorized Official

Authorized Official Last Name:
MCAFEE
Authorized Official First Name:
MIKE
Authorized Official Middle Name:
Authorized Official Title or Position:
PIC
Authorized Official Telephone Number:
573-778-1608

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  2013001184 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2140112 . This is a "PK" identifier . This identifiers is of the category "OTHER".




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