Healthcare Provider Details

I. General information

NPI: 1942847413
Provider Name (Legal Business Name): SOUTHEAST HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/04/2019
Last Update Date: 03/05/2024
Certification Date: 03/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2600 E. MAIN STREET SUITE 113
JACKSON MO
63755
US

IV. Provider business mailing address

2600 E. MAIN STREET SUITE 113
JACKSON MO
63755
US

V. Phone/Fax

Practice location:
  • Phone: 573-755-2315
  • Fax: 573-519-4676
Mailing address:
  • Phone: 573-755-2315
  • Fax: 573-519-4676

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 Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State

VIII. Authorized Official

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