Basic Information
| Provider Information | |||||||||
| NPI: | 1831407113 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NORTHEAST PHARMACEUTICALS INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | NORTHEAST PHARMACEUTICALS-GREENVILLE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3480 EASTERN BLVD | ||||||||
| Address2: | |||||||||
| City: | MONTGOMERY | ||||||||
| State: | AL | ||||||||
| PostalCode: | 361161700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3348194500 | ||||||||
| FaxNumber: | 3343568347 | ||||||||
| Practice Location | |||||||||
| Address1: | 1707 HOSPITAL ST | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | MS | ||||||||
| PostalCode: | 387033225 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3343567627 | ||||||||
| FaxNumber: | 3343568347 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2010 | ||||||||
| LastUpdateDate: | 12/21/2015 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PORTER | ||||||||
| AuthorizedOfficialFirstName: | LATONYA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 3343567627 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336S0011X | N | Suppliers | Pharmacy | Specialty Pharmacy | 333600000X | N | Suppliers | Pharmacy | 3336L0003X | 08654 | MS | Y | Suppliers | Pharmacy | Long Term Care Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 2126839 | 01 | PK | OTHER | 08631311 | 05 | MS | MEDICAID |