Healthcare Provider Details

I. General information

NPI: 1467783209
Provider Name (Legal Business Name): SOUTHEASTERN MEDICAL COMPOUNDING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/19/2010
Last Update Date: 06/11/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

709 MALL BLVD RM 356B
SAVANNAH GA
31406-4805
US

IV. Provider business mailing address

7370 HODGSON MEMORIAL DR # C5-B
SAVANNAH GA
31406-2536
US

V. Phone/Fax

Practice location:
  • Phone: 912-201-8138
  • Fax: 877-329-0079
Mailing address:
  • Phone: 912-401-3234
  • Fax: 877-329-0079

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberY006009
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License NumberPHRE009607
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number2013005924
License Number StateMO
# 4
Primary TaxonomyY
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number114078
License Number StateAL
# 5
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number5301009997
License Number StateMI
# 6
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number264044
License Number StateMN
# 7
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number27038
License Number StateTX
# 8
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License NumberPH25026
License Number StateFL
# 9
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number022297550
License Number StateOH

VIII. Authorized Official

Name: JOHN KENNEDY
Title or Position: VICE PRESIDENT
Credential:
Phone: 912-201-8138