Basic Information
| Provider Information | |||||||||
| NPI: | 1194824458 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | REYNOLDS ARMY COMMUNITY HOSPITAL | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | SILL MAIN OP PHCY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3009 N WILSON RD ATTN MCUA-PAD-PF | ||||||||
| Address2: | 4300 THOMAS ST BLDG 4300 | ||||||||
| City: | FT SILL | ||||||||
| State: | OK | ||||||||
| PostalCode: | 735039042 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | REYNOLDS COMM HOSP DEPT OF PHCY | ||||||||
| Address2: | 4300 THOMAS ST BLDG 4300 | ||||||||
| City: | FT SILL | ||||||||
| State: | OK | ||||||||
| PostalCode: | 73503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5804582300 | ||||||||
| FaxNumber: | 5804582445 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/22/2006 | ||||||||
| 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 | 34540 | OK | Y | Suppliers | Military/U.S. Coast Guard Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 2076246 | 01 | PK | OTHER |