Basic Information
| Provider Information | |||||||||
| NPI: | 1194138859 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MONCRIEF ARMY COMMUNITY HOSPITAL | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | DOD FT JACKSON EPHCY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | MONCRIEF ARMY COMMUNITY HOSPITAL | ||||||||
| Address2: | 4500 STUART ST BOX 497 | ||||||||
| City: | FORT JACKSON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292075700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8037512415 | ||||||||
| FaxNumber: | 8037512048 | ||||||||
| Practice Location | |||||||||
| Address1: | 4500 STUART AVE | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292075700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8034193830 | ||||||||
| FaxNumber: | 8034193845 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2014 | ||||||||
| LastUpdateDate: | 02/27/2017 | ||||||||
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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 | 333600000X | N | Suppliers | Pharmacy | 332000000X | Y | Suppliers | Military/U.S. Coast Guard Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 2146206 | 01 | PK | OTHER |