Basic Information
| Provider Information | |||||||||
| NPI: | 1134226988 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MCDONALD ARMY HEALTH CENTER | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | STORY PHCY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 579 JEFFERSON AVE | ||||||||
| Address2: | ATTN: UBO | ||||||||
| City: | FT EUSTIS | ||||||||
| State: | VA | ||||||||
| PostalCode: | 236041526 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7573147881 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 649 NEW GUINEA RD | ||||||||
| Address2: | |||||||||
| City: | FT STORY | ||||||||
| State: | VA | ||||||||
| PostalCode: | 23459 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7574227822 | ||||||||
| FaxNumber: | 7573147764 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2006 | ||||||||
| LastUpdateDate: | 01/20/2016 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MORALES | ||||||||
| AuthorizedOfficialFirstName: | HECTOR | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF DHA PASS | ||||||||
| AuthorizedOfficialTelephone: | 2105366650 | ||||||||
| IsSoleProprietor: | |||||||||
| 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 | 2104765 | 01 | PK | OTHER |