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General NPI Number Information
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NPI Number | 1396189767
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Entity Type | Organization
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Legal Business Name | SOUTHEAST HEALTH PHARMACY LLC
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Dates
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Enumeration Date | 04/29/2013
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Last Update Date | 02/03/2016
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Provider Practice Location Address
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Address Line | 2002 KANELL BLVD STE 102
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City | POPLAR BLUFF
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State | MO
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Zip | 63901-4045
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Country | US
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Telephone | 573-778-1608
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Fax | 573-778-1645
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Provider Business Mailing Address
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Address Line | PO BOX 989
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City | POPLAR BLUFF
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State | MO
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Zip | 63902-0989
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Country | US
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Telephone | 573-778-1608
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Fax | 573-778-1645
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Authorized Official
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Title or Position | PIC
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Name | MIKE MCAFEE
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Credential |
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Telephone | 573-778-1608
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number | 2013001184
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License Number State | MO
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