Provider Demographics
NPI:1073514477
Name:PROFESSIONAL COMPOUNDING CENTER OF SOUTHEAST NEBRASKA INC
Entity Type:Organization
Organization Name:PROFESSIONAL COMPOUNDING CENTER OF SOUTHEAST NEBRASKA INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MITCHELL
Authorized Official - Middle Name:E
Authorized Official - Last Name:DEINES
Authorized Official - Suffix:
Authorized Official - Credentials:RP
Authorized Official - Phone:402-223-4774
Mailing Address - Street 1:910 E COURT ST
Mailing Address - Street 2:STE B
Mailing Address - City:BEATRICE
Mailing Address - State:NE
Mailing Address - Zip Code:68310-4085
Mailing Address - Country:US
Mailing Address - Phone:402-223-4774
Mailing Address - Fax:402-223-5610
Practice Address - Street 1:910 E COURT ST
Practice Address - Street 2:STE B
Practice Address - City:BEATRICE
Practice Address - State:NE
Practice Address - Zip Code:68310-4085
Practice Address - Country:US
Practice Address - Phone:402-223-4774
Practice Address - Fax:402-223-5610
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE2345183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE47074248301Medicaid
36931OtherBLUE CROSS
1280540001Medicare ID - Type Unspecified