Provider Demographics
NPI:1336818087
Name:SOUTHEAST COMMUNITY PHARMACY
Entity Type:Organization
Organization Name:SOUTHEAST COMMUNITY PHARMACY
Other - Org Name:SOUTHEAST COMMUNITY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:COLEMAN
Authorized Official - Last Name:MITCHELL
Authorized Official - Suffix:JR
Authorized Official - Credentials:RPH
Authorized Official - Phone:757-586-5552
Mailing Address - Street 1:2315 JEFFERSON AVE
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23607-4509
Mailing Address - Country:US
Mailing Address - Phone:757-586-5552
Mailing Address - Fax:757-586-5558
Practice Address - Street 1:2315 JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23607-4509
Practice Address - Country:US
Practice Address - Phone:757-586-5552
Practice Address - Fax:757-586-5558
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-07
Last Update Date:2023-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1336818087Medicaid