Provider Demographics
NPI:1669654687
Name:SOUTHEASTERN PHARMACUETICALS
Entity Type:Organization
Organization Name:SOUTHEASTERN PHARMACUETICALS
Other - Org Name:CORLEY DRUGS #9
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:H
Authorized Official - Last Name:BURTON
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:706-884-2517
Mailing Address - Street 1:18 NEW AIRPORT RD
Mailing Address - Street 2:STE B
Mailing Address - City:LAGRANGE
Mailing Address - State:GA
Mailing Address - Zip Code:30240-1410
Mailing Address - Country:US
Mailing Address - Phone:706-885-9213
Mailing Address - Fax:
Practice Address - Street 1:229 DAVIS ROAD
Practice Address - Street 2:STE 900
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30241-2546
Practice Address - Country:US
Practice Address - Phone:706-298-6870
Practice Address - Fax:706-298-6875
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-30
Last Update Date:2009-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHRE0094163336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA97933748AMedicaid
GA5845880001Medicare NSC