Provider Demographics
NPI:1821353657
Name:NORTHEAST PHARMACEUTICALS, INC.
Entity Type:Organization
Organization Name:NORTHEAST PHARMACEUTICALS, INC.
Other - Org Name:NORTHEAST PHARMACEUTICALS, INC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:KRYSTAL
Authorized Official - Middle Name:
Authorized Official - Last Name:MIMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-356-7627
Mailing Address - Street 1:3480 EASTERN BLVD
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36116-1700
Mailing Address - Country:US
Mailing Address - Phone:334-356-7627
Mailing Address - Fax:334-356-8347
Practice Address - Street 1:6 MATHIS DR NW
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30165-1242
Practice Address - Country:US
Practice Address - Phone:706-237-6306
Practice Address - Fax:706-622-2135
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-09
Last Update Date:2014-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHRE0098393336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1162611OtherNCPDP PROVIDER IDENTIFICATION NUMBER