Provider Demographics
NPI:1568761963
Name:SOUTHEASTERN REGIONAL MEDICAL CENTER
Entity Type:Organization
Organization Name:SOUTHEASTERN REGIONAL MEDICAL CENTER
Other - Org Name:SOUTHEASTERN PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY SUPERVISOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:EDGE
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:910-735-8806
Mailing Address - Street 1:300 W 27TH ST.
Mailing Address - Street 2:
Mailing Address - City:LUMBERTON
Mailing Address - State:NC
Mailing Address - Zip Code:28358-3098
Mailing Address - Country:US
Mailing Address - Phone:910-735-8806
Mailing Address - Fax:910-735-8803
Practice Address - Street 1:300 W 27TH ST
Practice Address - Street 2:
Practice Address - City:LUMBERTON
Practice Address - State:NC
Practice Address - Zip Code:28358-3075
Practice Address - Country:US
Practice Address - Phone:910-735-8806
Practice Address - Fax:910-735-8803
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-24
Last Update Date:2013-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC10389333600000X
3336C0003X, 3336C0004X, 3336H0001X, 3336L0003X, 3336M0002X, 3336M0003X, 3336N0007X, 3336S0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336M0002XSuppliersPharmacyMail Order Pharmacy
No3336M0003XSuppliersPharmacyManaged Care Organization Pharmacy
No3336N0007XSuppliersPharmacyNuclear Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6557480001Medicare NSC