Basic Information
| Provider Information | |||||||||
| NPI: | 1528488848 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MADIGAN ARMY MEDICAL CTR | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | DOD LEWIS EPHCY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | MADIGAN ARMY MEDICAL CTR | ||||||||
| Address2: | ATTN: MCHJ-PD-MSA | ||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984310001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2539682586 | ||||||||
| FaxNumber: | 2539683349 | ||||||||
| Practice Location | |||||||||
| Address1: | MADIGAN ARMY MEDICAL CTR 9040 | ||||||||
| Address2: | JACKSON AVE | ||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984311100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2539682586 | ||||||||
| FaxNumber: | 2539683349 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/25/2014 | ||||||||
| LastUpdateDate: | 04/30/2014 | ||||||||
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| AuthorizedOfficialLastName: | MORALES | ||||||||
| AuthorizedOfficialFirstName: | HECTOR | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF DHA PASS | ||||||||
| 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 | 2145489 | 01 | PK | OTHER |