Provider Demographics
NPI:1346596574
Name:SOUTHEASTERN REGIONAL MEDICAL CENTER, INC.
Entity Type:Organization
Organization Name:SOUTHEASTERN REGIONAL MEDICAL CENTER, INC.
Other - Org Name:SOUTHEASTERN REGIONAL MEDICAL CENTER RETAIL PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT OF PHARMACY SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:JOEL
Authorized Official - Middle Name:
Authorized Official - Last Name:WRIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:806-242-7782
Mailing Address - Street 1:320 S POLK ST STE 200
Mailing Address - Street 2:
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79101-1436
Mailing Address - Country:US
Mailing Address - Phone:806-242-7782
Mailing Address - Fax:404-348-0453
Practice Address - Street 1:600 CELEBRATE LIFE PKWY STE A176A
Practice Address - Street 2:
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30265-8001
Practice Address - Country:US
Practice Address - Phone:770-400-6392
Practice Address - Fax:404-348-0453
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-25
Last Update Date:2024-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003195531AMedicaid
1162661OtherNCPDP PROVIDER IDENTIFICATION NUMBER