Provider Demographics
NPI:1700160579
Name:DURA-MED SOUTHEAST INC
Entity type:Organization
Organization Name:DURA-MED SOUTHEAST INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:MISTY
Authorized Official - Middle Name:
Authorized Official - Last Name:HERRING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-675-6850
Mailing Address - Street 1:110 LEWIS ST
Mailing Address - Street 2:
Mailing Address - City:EVERGREEN
Mailing Address - State:AL
Mailing Address - Zip Code:36401-3317
Mailing Address - Country:US
Mailing Address - Phone:251-578-9065
Mailing Address - Fax:251-578-1006
Practice Address - Street 1:110 LEWIS ST
Practice Address - Street 2:
Practice Address - City:EVERGREEN
Practice Address - State:AL
Practice Address - Zip Code:36401-3317
Practice Address - Country:US
Practice Address - Phone:251-578-9065
Practice Address - Fax:251-578-1006
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-28
Last Update Date:2012-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
AL1138403336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
0137489OtherNCPDP PROVIDER IDENTIFICATION NUMBER