Basic Information
| Provider Information | |||||||||
| NPI: | 1285733576 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WOMACK ARMY MEDICAL CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | BRAGG OP NEW WAMC PHCY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | WOMACK ARMY MEDICAL CTR | ||||||||
| Address2: | 2817 REILLY RD | ||||||||
| City: | FORT BRAGG | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283107301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9109078024 | ||||||||
| FaxNumber: | 9104324638 | ||||||||
| Practice Location | |||||||||
| Address1: | REILY RD BLDG 42817 | ||||||||
| Address2: | |||||||||
| City: | FORT BRAGG | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283100001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9109078024 | ||||||||
| FaxNumber: | 9104324638 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/22/2006 | ||||||||
| LastUpdateDate: | 02/18/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MORALES | ||||||||
| AuthorizedOfficialFirstName: | HECTOR | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF DHA PASS | ||||||||
| AuthorizedOfficialTelephone: | 2105366650 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/18/2020 | ||||||||
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 | 2068467 | 01 | PK | OTHER |