Provider Demographics
NPI:1467783209
Name:SOUTHEASTERN MEDICAL COMPOUNDING LLC
Entity Type:Organization
Organization Name:SOUTHEASTERN MEDICAL COMPOUNDING LLC
Other - Org Name:SOUTHEASTERN MEDICAL COMPOUNDING LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:KENNEDY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-201-8138
Mailing Address - Street 1:7370 HODGSON MEMORIAL DR # C5-B
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31406-2536
Mailing Address - Country:US
Mailing Address - Phone:912-401-3234
Mailing Address - Fax:877-329-0079
Practice Address - Street 1:709 MALL BLVD RM 356B
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31406-4805
Practice Address - Country:US
Practice Address - Phone:912-201-8138
Practice Address - Fax:877-329-0079
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-19
Last Update Date:2015-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZY0060093336C0003X
GAPHRE0096073336C0004X
MO20130059243336C0004X
AL1140783336C0004X
MI53010099973336C0004X
MN2640443336C0004X
TX270383336C0004X
FLPH250263336C0004X
OH0222975503336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2140641OtherPK