=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154459816
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUTHEAST FOODS, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/02/2007
-----------------------------------------------------
Last Update Date | 03/02/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3111 HIGHWAY 80 E
-----------------------------------------------------
City | PEARL
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39208-3503
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-932-5337
-----------------------------------------------------
Fax | 601-932-7952
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3111 HIGHWAY 80 E
-----------------------------------------------------
City | PEARL
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39208-3503
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-932-5337
-----------------------------------------------------
Fax | 601-932-7952
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CFO
-----------------------------------------------------
Name | CHARLES DEDMON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 318-388-1884
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 03618012
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------