Basic Information
| Provider Information | |||||||||
| NPI: | 1962042028 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SOUTHEAST COMMUNITY HEALTH SYSTEMS PHARMACY KENTWOOD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 770 | ||||||||
| Address2: | |||||||||
| City: | ZACHARY | ||||||||
| State: | LA | ||||||||
| PostalCode: | 707910770 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2253062000 | ||||||||
| FaxNumber: | 2256581282 | ||||||||
| Practice Location | |||||||||
| Address1: | 734 AVENUE G | ||||||||
| Address2: | |||||||||
| City: | KENTWOOD | ||||||||
| State: | LA | ||||||||
| PostalCode: | 704442602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2253062100 | ||||||||
| FaxNumber: | 9852296828 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/07/2020 | ||||||||
| LastUpdateDate: | 01/07/2020 | ||||||||
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| AuthorizedOfficialLastName: | CYPRIAN | ||||||||
| AuthorizedOfficialFirstName: | ALECIA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 2253062000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SOUTHEAST COMMUNITY HEALTH SYSTEMS | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | PHD | ||||||||
| NPICertificationDate: | 01/07/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 333600000X | Y | Suppliers | Pharmacy |
No ID Information.