Basic Information
Provider Information | |||||||||
NPI: | 1063519817 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | WALTER REED NATIONAL MILITARY MED CENTER | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | CARLISLE DUNHAM MAIN PHCY | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | MCXR-CBK-TPC 450 GIBNER RD STE 1 | ||||||||
Address2: | 2480 LLEWELLYN AVE STE 5800 | ||||||||
City: | CARLISLE BARRACKS | ||||||||
State: | PA | ||||||||
PostalCode: | 17013 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2102218274 | ||||||||
FaxNumber: | 2102952567 | ||||||||
Practice Location | |||||||||
Address1: | 450 GIBNER RD | ||||||||
Address2: |   | ||||||||
City: | CARLISLE BARRACKS | ||||||||
State: | PA | ||||||||
PostalCode: | 170135090 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7172454509 | ||||||||
FaxNumber: | 7172453815 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/20/2006 | ||||||||
LastUpdateDate: | 06/08/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
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 | 2085493 | 01 |   | PK | OTHER |