Provider Demographics
NPI:1104807783
Name:SOUTHEASTERN MEDICAL SUPPLY CO
Entity type:Organization
Organization Name:SOUTHEASTERN MEDICAL SUPPLY CO
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:C
Authorized Official - Last Name:STRANGE
Authorized Official - Suffix:
Authorized Official - Credentials:RFO
Authorized Official - Phone:803-419-6766
Mailing Address - Street 1:7221 BROOKFIELD RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29223-2215
Mailing Address - Country:US
Mailing Address - Phone:803-419-6766
Mailing Address - Fax:803-419-6645
Practice Address - Street 1:7221 BROOKFIELD RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29223-2215
Practice Address - Country:US
Practice Address - Phone:803-419-6766
Practice Address - Fax:803-419-6645
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-09
Last Update Date:2009-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCDE1551Medicaid
SCDE1551Medicaid