Provider Demographics
NPI:1871896951
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:SUPERVISING PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:MISTY
Authorized Official - Middle Name:
Authorized Official - Last Name:BLACKMON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-365-0685
Mailing Address - Street 1:PO BOX 640
Mailing Address - Street 2:
Mailing Address - City:JAY
Mailing Address - State:FL
Mailing Address - Zip Code:32565-0640
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3877 HIGHWAY 4
Practice Address - Street 2:
Practice Address - City:JAY
Practice Address - State:FL
Practice Address - Zip Code:32565-1754
Practice Address - Country:US
Practice Address - Phone:850-675-2448
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-13
Last Update Date:2011-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL251553336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
5703132OtherNCPDP PROVIDER IDENTIFICATION NUMBER