Basic Information
| Provider Information | |||||||||
| NPI: | 1295832046 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WRAMC | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | WALTER REED MAIN PHCY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 9300 DEWITT LOOP | ||||||||
| Address2: | ATTN FBCH OTPT TPCP | ||||||||
| City: | FORT BELVOIR | ||||||||
| State: | VA | ||||||||
| PostalCode: | 220605901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5712312856 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 6900 GEORGIA AVE NW | ||||||||
| Address2: | |||||||||
| City: | WASHINGTON | ||||||||
| State: | DC | ||||||||
| PostalCode: | 203070001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2102218274 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2006 | ||||||||
| LastUpdateDate: | 02/21/2013 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MORALES | ||||||||
| AuthorizedOfficialFirstName: | HECTOR | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MGR PHRMCY OPERATIONS CNTR | ||||||||
| AuthorizedOfficialTelephone: | 2102218274 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | WRAMC | ||||||||
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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 | 0904056 | 01 | OTHER ID NUMBER-COMMERCIAL NUMBER | OTHER | 1063441905 | 01 | PARENT NPI | OTHER |