Basic Information
| Provider Information | |||||||||
| NPI: | 1215036546 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NAVAL HEALTH CLINIC CHERRY POINT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4389 BEAUFORT RD | ||||||||
| Address2: | |||||||||
| City: | CHERRY POINT | ||||||||
| State: | NC | ||||||||
| PostalCode: | 285330023 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2102218474 | ||||||||
| FaxNumber: | 2102952567 | ||||||||
| Practice Location | |||||||||
| Address1: | BLDG 4389 BEAUFORT ST | ||||||||
| Address2: | |||||||||
| City: | CHERRY POINT | ||||||||
| State: | NC | ||||||||
| PostalCode: | 285330023 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2524660252 | ||||||||
| FaxNumber: | 2524660286 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/22/2006 | ||||||||
| LastUpdateDate: | 10/11/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 07/17/2007 | ||||||||
| NPIReactivationDate: | 05/09/2008 | ||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CONDON | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | BUMED UBO | ||||||||
| AuthorizedOfficialTelephone: | 2404013643 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | NAVAL HEALTH CLINIC CHERRY POINT | ||||||||
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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 | 3400135 | 05 | NC | MEDICAID | 2070473 | 01 | PK | OTHER |