MEDICARE: SOUTHEAST PHARMACY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3336C0003X	Community/Retail Pharmacy	1277321703	UT

General Provider Information

NPI Number	:	1114089794
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHEAST PHARMACY

Provider Business Mailing Address
First Line	:	2670 S 2000 E
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84109-1736
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2670 S 2000 E
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84109-1736
Country	:	US
Telephone Number	:	801-466-2181
Fax Number	:

Authorized Official
Title or Position	:	PHARMACIST
Name	:	ROBERT R HUNTER
Credential	:
Telephone Number	:	801-466-2181

Provider Enumeration Date	:	12/13/2006
Last Update Date	:	08/22/2020

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Directions to “SOUTHEAST PHARMACY ” Practice Location

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