Provider Demographics
NPI:1396189767
Name:SOUTHEAST HEALTH PHARMACY LLC
Entity Type:Organization
Organization Name:SOUTHEAST HEALTH PHARMACY LLC
Other - Org Name:SOUTHEASTHEALTH PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PIC
Authorized Official - Prefix:
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:
Authorized Official - Last Name:MCAFEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-778-1608
Mailing Address - Street 1:PO BOX 989
Mailing Address - Street 2:
Mailing Address - City:POPLAR BLUFF
Mailing Address - State:MO
Mailing Address - Zip Code:63902-0989
Mailing Address - Country:US
Mailing Address - Phone:573-778-1608
Mailing Address - Fax:573-778-1645
Practice Address - Street 1:2002 KANELL BLVD
Practice Address - Street 2:STE 102
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901-4045
Practice Address - Country:US
Practice Address - Phone:573-778-1608
Practice Address - Fax:573-778-1645
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-29
Last Update Date:2016-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20130011843336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2140112OtherPK