MEDICARE: NORTHEAST PHARMACEUTICALS INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3336S0011X	Specialty Pharmacy
2	333600000X	Pharmacy
3	3336L0003X	Long Term Care Pharmacy	08654	MS

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2126839	OTHER		PK
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1831407113
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTHEAST PHARMACEUTICALS INC

Provider Business Mailing Address
First Line	:	3480 EASTERN BLVD
Second Line	:
City	:	MONTGOMERY
State	:	AL
Zip	:	36116-1700
Country	:	US
Telephone Number	:	334-819-4500
Fax Number	:	334-356-8347

Provider Business Practice Location Address
First Line	:	1707 HOSPITAL ST
Second Line	:
City	:	GREENVILLE
State	:	MS
Zip	:	38703-3225
Country	:	US
Telephone Number	:	334-356-7627
Fax Number	:	334-356-8347

Authorized Official
Title or Position	:	DIRECTOR OF OPERATIONS
Name	:	LATONYA PORTER
Credential	:
Telephone Number	:	334-356-7627

Provider Enumeration Date	:	09/20/2010
Last Update Date	:	12/21/2015

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Directions to “NORTHEAST PHARMACEUTICALS INC ” Practice Location

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