Provider Demographics
NPI:1356748057
Name:SOUTHEASTERN PHARMACY HEALTH PARK
Entity type:Organization
Organization Name:SOUTHEASTERN PHARMACY HEALTH PARK
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OUTPATIENT PHARMACY SUPERVISOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:EDGE
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:910-735-8806
Mailing Address - Street 1:4901 DAWN DR STE 1200
Mailing Address - Street 2:
Mailing Address - City:LUMBERTON
Mailing Address - State:NC
Mailing Address - Zip Code:28360-8207
Mailing Address - Country:US
Mailing Address - Phone:910-671-4223
Mailing Address - Fax:910-671-4224
Practice Address - Street 1:4901 DAWN DR STE 1200
Practice Address - Street 2:
Practice Address - City:LUMBERTON
Practice Address - State:NC
Practice Address - Zip Code:28360-8207
Practice Address - Country:US
Practice Address - Phone:910-671-4223
Practice Address - Fax:910-671-4224
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-24
Last Update Date:2014-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC12148333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy