Basic Information
| Provider Information | |||||||||
| NPI: | 1457849556 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KIMBROUGH ACC MILITARY MTF | ||||||||
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| Mailing Information | |||||||||
| Address1: | FT INDIANTOWN GAP | ||||||||
| Address2: | BLDG 4-114 | ||||||||
| City: | ANNVILLE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 17003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7178612091 | ||||||||
| FaxNumber: | 7178612429 | ||||||||
| Practice Location | |||||||||
| Address1: | FT INDIANTOWN GAP | ||||||||
| Address2: | BLDG 4-114 | ||||||||
| City: | ANNVILLE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 17003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7178612091 | ||||||||
| FaxNumber: | 7178612429 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/25/2018 | ||||||||
| LastUpdateDate: | 04/27/2018 | ||||||||
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| AuthorizedOfficialLastName: | MORALES | ||||||||
| AuthorizedOfficialFirstName: | HECTOR | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF OF PASS | ||||||||
| AuthorizedOfficialTelephone: | 2105366650 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 333600000X | N | Suppliers | Pharmacy | 332000000X | Y | Suppliers | Military/U.S. Coast Guard Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 2177351 | 01 | PK | OTHER |