Basic Information
| Provider Information | |||||||||
| NPI: | 1477652592 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MCDONALD ARMY HEALTH CENTER | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | EUSTIS TP PHCY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 579 JEFFERSON AVE | ||||||||
| Address2: | ATTN UBO | ||||||||
| City: | FT EUSTIS | ||||||||
| State: | VA | ||||||||
| PostalCode: | 23604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7573147672 | ||||||||
| FaxNumber: | 7573147764 | ||||||||
| Practice Location | |||||||||
| Address1: | 576 JEFFERSON AVE | ||||||||
| Address2: | ROOM 34 | ||||||||
| City: | FORT EUSTIS | ||||||||
| State: | VA | ||||||||
| PostalCode: | 236041373 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7573147672 | ||||||||
| FaxNumber: | 7573147764 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/22/2006 | ||||||||
| LastUpdateDate: | 06/18/2015 | ||||||||
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| AuthorizedOfficialLastName: | MORALES | ||||||||
| AuthorizedOfficialFirstName: | HECTOR | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF DHA PASS | ||||||||
| AuthorizedOfficialTelephone: | 2105366650 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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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 | 2104764 | 01 | PK | OTHER |