Basic Information
| Provider Information | |||||||||
| NPI: | 1518066273 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EVANS ARMY COMMUNITY HOSPITAL | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CARSON COMMISSARY PHARMACY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | EVANS ARMY COMMUNITY HOSPITAL | ||||||||
| Address2: | 1650 COCHRANE CIR ATTN THIRD PARTY OFFICE | ||||||||
| City: | FT CARSON | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809134603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2102218274 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 6351 WETZEL AVE | ||||||||
| Address2: | BLDG 1525 | ||||||||
| City: | FT CARSON | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809134188 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195241060 | ||||||||
| FaxNumber: | 7195267749 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2006 | ||||||||
| LastUpdateDate: | 01/20/2015 | ||||||||
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| AuthorizedOfficialLastName: | MORALES | ||||||||
| AuthorizedOfficialFirstName: | HECTOR | ||||||||
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| AuthorizedOfficialTitleorPosition: | DEPUTY DIRECTOR PHCY OPS CTR | ||||||||
| AuthorizedOfficialTelephone: | 2102218443 | ||||||||
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| 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 | 2003338 | 01 | PK | OTHER |