Basic Information
Provider Information
NPI: 1366612574
EntityType: 2
ReplacementNPI:  
OrganizationName: EVANS ARMY COMMUNITY HOSPITAL
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName: CARSON REFILL PHCY
OtherOrganizationType: 3
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: EVANS ARMY COMMUNITY HOSPITAL
Address2: ATTN: THIRD PARTY OFFICE 1650 COCHRANE CIR
City: FT CARSON
State: CO
PostalCode: 809134604
CountryCode: US
TelephoneNumber:  
FaxNumber:  
Practice Location
Address1: 1650 COCHRANE CIR
Address2: BLDG 7500
City: FT CARSON
State: CO
PostalCode: 809134613
CountryCode: US
TelephoneNumber: 7195241060
FaxNumber: 7195267449
Other Information
ProviderEnumerationDate: 03/04/2008
LastUpdateDate: 10/07/2015
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: MORALES
AuthorizedOfficialFirstName: HECTOR
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition: CHIEF DHA PASS
AuthorizedOfficialTelephone: 2105366650
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
332000000X  Y SuppliersMilitary/U.S. Coast Guard Pharmacy 

ID Information
IDTypeStateIssuerDescription
200342501 PKOTHER


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