Provider Demographics
NPI:1336165547
Name:SOUTHEASTERN PHARMACY LLC
Entity Type:Organization
Organization Name:SOUTHEASTERN PHARMACY LLC
Other - Org Name:ALTAMA PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:LEWIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-264-2622
Mailing Address - Street 1:5711 ALTAMA AVE
Mailing Address - Street 2:SUITE G
Mailing Address - City:BRUNSWICK
Mailing Address - State:GA
Mailing Address - Zip Code:31525-2240
Mailing Address - Country:US
Mailing Address - Phone:912-264-2622
Mailing Address - Fax:912-264-1392
Practice Address - Street 1:5711 ALTAMA AVE
Practice Address - Street 2:UNIT G
Practice Address - City:BRUNSWICK
Practice Address - State:GA
Practice Address - Zip Code:31525-2240
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:2006-07-14
Last Update Date:2020-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0027333336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000028256AMedicaid
GA1106930OtherNABP
GA1106930Medicaid
GA1106930OtherNABP
GA1259490001Medicare NSC