Provider Demographics
NPI:1437320686
Name:SOUTHEASTERN MEDICAL SUPPLY LLC
Entity Type:Organization
Organization Name:SOUTHEASTERN MEDICAL SUPPLY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:BARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:MAHAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:606-258-0001
Mailing Address - Street 1:PO BOX 1565
Mailing Address - Street 2:
Mailing Address - City:CORBIN
Mailing Address - State:KY
Mailing Address - Zip Code:40702-1565
Mailing Address - Country:US
Mailing Address - Phone:606-258-0001
Mailing Address - Fax:606-258-0021
Practice Address - Street 1:120 N LAUREL AVE
Practice Address - Street 2:
Practice Address - City:CORBIN
Practice Address - State:KY
Practice Address - Zip Code:40701-1235
Practice Address - Country:US
Practice Address - Phone:606-258-0001
Practice Address - Fax:606-258-0021
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-16
Last Update Date:2021-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY6302970001Medicare NSC