Basic Information
| Provider Information | |||||||||
| NPI: | 1053724807 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GAHCC-TPCP | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | DOD FT DRUM EPHCY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | GAHCC-TPCP | ||||||||
| Address2: | 11050 MT. BELVEDERE BOULEVARD | ||||||||
| City: | FORT DRUM | ||||||||
| State: | NY | ||||||||
| PostalCode: | 136025004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3157723696 | ||||||||
| FaxNumber: | 3157721691 | ||||||||
| Practice Location | |||||||||
| Address1: | GUTHRIE AMBULATORY HEALTH CARE CLINIC | ||||||||
| Address2: | 11050 MT. BELVEDE | ||||||||
| City: | FORT DRUM | ||||||||
| State: | NY | ||||||||
| PostalCode: | 136025004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3157723696 | ||||||||
| FaxNumber: | 3157721691 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2014 | ||||||||
| LastUpdateDate: | 02/17/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MORALES | ||||||||
| AuthorizedOfficialFirstName: | HECTOR | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF DHA PASS | ||||||||
| AuthorizedOfficialTelephone: | 2105366650 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332000000X | Y | Suppliers | Military/U.S. Coast Guard Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 2146180 | 01 | PK | OTHER |