Basic Information
Provider Information | |||||||||
NPI: | 1477811149 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | WINN - THIRD PARTY INSURANCE | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | STEWART BCT TMC PHCY | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | BLDG 8435 | ||||||||
Address2: | 306 VANGUARD ROAD | ||||||||
City: | FT STEWART | ||||||||
State: | GA | ||||||||
PostalCode: | 31314 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9124356745 | ||||||||
FaxNumber: | 9124355450 | ||||||||
Practice Location | |||||||||
Address1: | BLDG 8435 | ||||||||
Address2: | 306 VANGUARD ROAD | ||||||||
City: | FT STEWART | ||||||||
State: | GA | ||||||||
PostalCode: | 31314 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9124356745 | ||||||||
FaxNumber: | 9124355450 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/01/2012 | ||||||||
LastUpdateDate: | 01/20/2016 | ||||||||
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
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332000000X |   |   | Y |   | Suppliers | Military/U.S. Coast Guard Pharmacy |   |
ID Information
ID | Type | State | Issuer | Description | 2135016 | 01 |   | PK | OTHER |