Basic Information
| Provider Information | |||||||||
| NPI: | 1316243744 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MADIGAN ARMY MEDICAL CTR | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MADIGAN PUYALLUP PHCY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9040A JACKSON AVE | ||||||||
| Address2: | ATTN: MCHJ-CSA-U | ||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984310001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2539686598 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 10507 156TH ST E | ||||||||
| Address2: | SUITE 112 | ||||||||
| City: | PUYALLUP | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983749361 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2533075433 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/02/2011 | ||||||||
| LastUpdateDate: | 09/30/2021 | ||||||||
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| AuthorizedOfficialLastName: | MORALES | ||||||||
| AuthorizedOfficialFirstName: | HECTOR | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DEPUTY DIRECTOR OF PHARMACY OPS | ||||||||
| AuthorizedOfficialTelephone: | 2102218274 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MADIGAN ARMY MEDICAL CTR | ||||||||
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| NPICertificationDate: | 09/30/2021 | ||||||||
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 | 4933924 | 01 | NCPDP | OTHER | 1841390077 | 01 | PARENT BILLING FACILITY NPI | OTHER | 1851605356 | 01 | FACILITY NPI | OTHER |