=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568761963
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUTHEASTERN REGIONAL MEDICAL CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/24/2011
-----------------------------------------------------
Last Update Date | 08/05/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 300 W 27TH ST
-----------------------------------------------------
City | LUMBERTON
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28358-3075
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-735-8806
-----------------------------------------------------
Fax | 910-735-8803
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 300 W 27TH ST.
-----------------------------------------------------
City | LUMBERTON
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28358-3098
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-735-8806
-----------------------------------------------------
Fax | 910-735-8803
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHARMACY SUPERVISOR
-----------------------------------------------------
Name | DR. JEFFREY LEE EDGE
-----------------------------------------------------
Credential | PHARM. D.
-----------------------------------------------------
Telephone | 910-735-8806
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336C0004X
-----------------------------------------------------
Taxonomy Name | Compounding Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 3336H0001X
-----------------------------------------------------
Taxonomy Name | Home Infusion Therapy Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 3336L0003X
-----------------------------------------------------
Taxonomy Name | Long Term Care Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 3336M0002X
-----------------------------------------------------
Taxonomy Name | Mail Order Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #6
-----------------------------------------------------
Taxonomy Code | 3336M0003X
-----------------------------------------------------
Taxonomy Name | Managed Care Organization Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #7
-----------------------------------------------------
Taxonomy Code | 3336N0007X
-----------------------------------------------------
Taxonomy Name | Nuclear Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #8
-----------------------------------------------------
Taxonomy Code | 3336S0011X
-----------------------------------------------------
Taxonomy Name | Specialty Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #9
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number | 10389
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------