Basic Information
| Provider Information | |||||||||
| NPI: | 1528167970 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | KELLER ARMY COMMUNITY HOSPITAL | ||||||||
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| OtherOrganizationName: | DIX TMC PHCY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 900 WASHINGTON RD | ||||||||
| Address2: | ATTN MCUD-RMD-UBO | ||||||||
| City: | WEST POINT | ||||||||
| State: | NY | ||||||||
| PostalCode: | 109961109 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 18TH ST AND DOUGHBOY LOOP BLDG 5660 | ||||||||
| Address2: | TROOP MEDICAL HEALTH CLINIC | ||||||||
| City: | FT DIX | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 08640 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8459382271 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/22/2006 | ||||||||
| LastUpdateDate: | 02/17/2011 | ||||||||
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| AuthorizedOfficialLastName: | MORALES | ||||||||
| AuthorizedOfficialFirstName: | HECTOR | ||||||||
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| AuthorizedOfficialTitleorPosition: | MGR PHRMCY OPERATIONS CNTR | ||||||||
| AuthorizedOfficialTelephone: | 2102218443 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | KELLER ARMY COMMUNITY HOSPITAL | ||||||||
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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 | 3141734 | 01 | OTHER ID NUMBER-COMMERCIAL NUMBER | OTHER | 1275747149 | 01 | FACILITY NPI | OTHER | 1528161916 | 01 | PARENT FACILITY NPI | OTHER |