Healthcare Provider Details

I. General information

NPI: 1336150846
Provider Name (Legal Business Name): SOUTHEAST HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/10/2006
Last Update Date: 01/13/2024
Certification Date: 01/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1723 BROADWAY STE 110
CAPE GIRARDEAU MO
63701
US

IV. Provider business mailing address

1723 BROADWAY STE 110
CAPE GIRARDEAU MO
63701
US

V. Phone/Fax

Practice location:
  • Phone: 573-331-7900
  • Fax: 573-331-7909
Mailing address:
  • Phone: 573-331-7900
  • Fax: 573-331-7909

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number006426
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: KRISTA BERRY
Title or Position: CFO
Credential:
Phone: 573-331-6028