Basic Information
Provider Information | |||||||||
NPI: | 1447496849 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | NORTHEAST PHARMACEUTICALS INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | NORTHEAST PHARMACEUTICALS-MOBILE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3480 EASTERN BLVD | ||||||||
Address2: |   | ||||||||
City: | MONTGOMERY | ||||||||
State: | AL | ||||||||
PostalCode: | 361161700 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3343567627 | ||||||||
FaxNumber: | 3343568347 | ||||||||
Practice Location | |||||||||
Address1: | 3456 HILLCREST RD | ||||||||
Address2: | BLDG B STE D | ||||||||
City: | MOBILE | ||||||||
State: | AL | ||||||||
PostalCode: | 366953195 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2516654521 | ||||||||
FaxNumber: | 2516654522 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/06/2009 | ||||||||
LastUpdateDate: | 07/15/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | PORTER | ||||||||
AuthorizedOfficialFirstName: | LATONYA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | DIRECTOR OF OPERATIONS | ||||||||
AuthorizedOfficialTelephone: | 3343567627 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336L0003X | 113227 | AL | Y |   | Suppliers | Pharmacy | Long Term Care Pharmacy |
ID Information
ID | Type | State | Issuer | Description | 2118729 | 01 |   | PK | OTHER |