Basic Information
| Provider Information | |||||||||
| NPI: | 1093877086 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WALTER REED NATIONAL MILITARY MED CENTER | ||||||||
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| OtherOrganizationName: | WOODBRIDGE NON-FORMULARY PHCY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9300 DEWITT LOOP | ||||||||
| Address2: | |||||||||
| City: | FORT BELVOIR | ||||||||
| State: | VA | ||||||||
| PostalCode: | 220605285 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5712312849 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3700 FETTLER PARK DR | ||||||||
| Address2: | |||||||||
| City: | DUMFRIES | ||||||||
| State: | VA | ||||||||
| PostalCode: | 220252050 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7034917668 | ||||||||
| FaxNumber: | 7035507136 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/15/2006 | ||||||||
| LastUpdateDate: | 03/18/2016 | ||||||||
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| AuthorizedOfficialLastName: | MORALES | ||||||||
| AuthorizedOfficialFirstName: | HECTOR | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF DHA PASS | ||||||||
| AuthorizedOfficialTelephone: | 2105366650 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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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 | 2105190 | 01 | PK | OTHER |