Provider Demographics
NPI:1811540867
Name:SOUTHEASTERN PHARMACY LLC
Entity Type:Organization
Organization Name:SOUTHEASTERN PHARMACY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PIC
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:LEWIS
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:912-264-2622
Mailing Address - Street 1:5711 ALTAMA AVE STE G
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:GA
Mailing Address - Zip Code:31525-2200
Mailing Address - Country:US
Mailing Address - Phone:912-264-2622
Mailing Address - Fax:912-264-1392
Practice Address - Street 1:5711 ALTAMA AVE STE G
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:GA
Practice Address - Zip Code:31525-2200
Practice Address - Country:US
Practice Address - Phone:912-264-2622
Practice Address - Fax:912-264-1392
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-18
Last Update Date:2019-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy