Provider Demographics
NPI:1154459816
Name:SOUTHEAST FOODS, INC.
Entity Type:Organization
Organization Name:SOUTHEAST FOODS, INC.
Other - Org Name:COUNTY MARKET PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:DEDMON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-388-1884
Mailing Address - Street 1:3111 HIGHWAY 80 E
Mailing Address - Street 2:
Mailing Address - City:PEARL
Mailing Address - State:MS
Mailing Address - Zip Code:39208-3503
Mailing Address - Country:US
Mailing Address - Phone:601-932-5337
Mailing Address - Fax:601-932-7952
Practice Address - Street 1:3111 HIGHWAY 80 E
Practice Address - Street 2:
Practice Address - City:PEARL
Practice Address - State:MS
Practice Address - Zip Code:39208-3503
Practice Address - Country:US
Practice Address - Phone:601-932-5337
Practice Address - Fax:601-932-7952
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-02
Last Update Date:2010-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS036180123336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2520674OtherNCPDP PROVIDER IDENTIFICATION NUMBER
MS00330610Medicaid