Basic Information
Provider Information | |||||||||
NPI: | 1457413403 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | TRIPLER ARMY MEDICAL CENTER | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | TRIPLER ER PHCY | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1 JARRETT WHITE RD | ||||||||
Address2: | ATTN PAD MCHK-PAT-T | ||||||||
City: | TRIPLER AMC | ||||||||
State: | HI | ||||||||
PostalCode: | 96859 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8084336103 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1 JARRETT WHITE RD | ||||||||
Address2: | ER PHCY | ||||||||
City: | TRIPLER AMC | ||||||||
State: | HI | ||||||||
PostalCode: | 96859 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8084335240 | ||||||||
FaxNumber: | 8084331682 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/15/2006 | ||||||||
LastUpdateDate: | 12/18/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MORALES | ||||||||
AuthorizedOfficialFirstName: | HECTOR | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PHARMACY OPERATIONS CENTER MGR | ||||||||
AuthorizedOfficialTelephone: | 2102218274 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | TRIPLER ARMY MEDICAL CENTER | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
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 | 1203986 | 01 |   | NCPDP | OTHER | 1831146281 | 01 |   | PARENT FACILITY NPI | OTHER |