Healthcare Provider Details

I. General information

NPI: 1295013530
Provider Name (Legal Business Name): NORTHEAST PHARMACEUTICALS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/03/2011
Last Update Date: 08/05/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

608 MARQUETTE ROAD
BRANDON MS
39042
US

IV. Provider business mailing address

608 MARQUETTE RD
BRANDON MS
39042
US

V. Phone/Fax

Practice location:
  • Phone: 334-356-7627
  • Fax: 334-356-8347
Mailing address:
  • Phone: 334-356-7627
  • Fax: 334-356-8347

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number09098
License Number StateMS

VIII. Authorized Official

Name: KRYSTAL L MIMS
Title or Position: DIRECTOR OF OPERATIONS
Credential:
Phone: 334-356-7627