Basic Information
| Provider Information | |||||||||
| NPI: | 1306915426 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | 121ST CSH/BAACH | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CAMP HIALEAH PHCY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2450 STANLEY RD STE 208 | ||||||||
| Address2: | |||||||||
| City: | FORT SAM HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782346108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2102218274 | ||||||||
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| Practice Location | |||||||||
| Address1: | BLDG 795 | ||||||||
| Address2: | |||||||||
| City: | CAMP HIALEAH | ||||||||
| State: | KOREA | ||||||||
| PostalCode: | AP | ||||||||
| CountryCode: | KR | ||||||||
| TelephoneNumber: | 2102218274 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/06/2006 | ||||||||
| LastUpdateDate: | 02/21/2013 | ||||||||
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| AuthorizedOfficialLastName: | MORALES | ||||||||
| AuthorizedOfficialFirstName: | HECTOR | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER PHARMACY OPERATIONS CENTER | ||||||||
| AuthorizedOfficialTelephone: | 2102218274 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | 121ST CSH/BAACH | ||||||||
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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 | 8210104 | 01 | NCPDP | OTHER |