Basic Information
Provider Information | |||||||||
NPI: | 1164730602 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | JAMES A LOVELL FEDERAL HEALTH CARE CENTER | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | USS TRANQUILITY TURN TWO PHARMACY | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 322 | ||||||||
Address2: |   | ||||||||
City: | NORTH CHICAGO | ||||||||
State: | IL | ||||||||
PostalCode: | 600640322 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8476881900 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2430 ILLINOIS STREET | ||||||||
Address2: |   | ||||||||
City: | GREAT LAKES | ||||||||
State: | IL | ||||||||
PostalCode: | 60088 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8476881900 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/17/2010 | ||||||||
LastUpdateDate: | 09/21/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MAYERICK | ||||||||
AuthorizedOfficialFirstName: | BARBARA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | DIRECTOR, BUSINESS DEVELOPMENT | ||||||||
AuthorizedOfficialTelephone: | 2024611550 | ||||||||
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 |   |
No ID Information.