=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871896951
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DURA-MED SOUTHEAST INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/13/2010
-----------------------------------------------------
Last Update Date | 02/08/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3877 HIGHWAY 4
-----------------------------------------------------
City | JAY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32565-1754
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-675-2448
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 640
-----------------------------------------------------
City | JAY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32565-0640
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SUPERVISING PHARMACIST
-----------------------------------------------------
Name | MISTY BLACKMON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 850-365-0685
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 25155
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------