Provider Demographics
NPI:1295013530
Name:NORTHEAST PHARMACEUTICALS, INC.
Entity Type:Organization
Organization Name:NORTHEAST PHARMACEUTICALS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:KRYSTAL
Authorized Official - Middle Name:L
Authorized Official - Last Name:MIMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-356-7627
Mailing Address - Street 1:608 MARQUETTE RD
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:MS
Mailing Address - Zip Code:39042
Mailing Address - Country:US
Mailing Address - Phone:334-356-7627
Mailing Address - Fax:334-356-8347
Practice Address - Street 1:608 MARQUETTE ROAD
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:MS
Practice Address - Zip Code:39042
Practice Address - Country:US
Practice Address - Phone:334-356-7627
Practice Address - Fax:334-356-8347
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-03
Last Update Date:2011-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS090983336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy