Basic Information
| Provider Information | |||||||||
| NPI: | 1619297991 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | 51 MED GP | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | TAEGU IDMT PHCY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 607 MMS/MSSG | ||||||||
| Address2: | UNIT 96213 | ||||||||
| City: | TAEGU | ||||||||
| State: | TAEGU | ||||||||
| PostalCode: | APO AP 96213 | ||||||||
| CountryCode: | KP | ||||||||
| TelephoneNumber: | 2102218443 | ||||||||
| FaxNumber: | 2102952567 | ||||||||
| Practice Location | |||||||||
| Address1: | 607 MMS/MSSG | ||||||||
| Address2: | UNIT 2166 | ||||||||
| City: | TAEGU | ||||||||
| State: | TAEGU | ||||||||
| PostalCode: | APO AP 96213 | ||||||||
| CountryCode: | KP | ||||||||
| TelephoneNumber: | 2102218443 | ||||||||
| FaxNumber: | 2102952567 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2010 | ||||||||
| LastUpdateDate: | 06/09/2010 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MORALES | ||||||||
| AuthorizedOfficialFirstName: | HECTOR | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DEPUTY DIRECTOR OF PHCY OPS | ||||||||
| AuthorizedOfficialTelephone: | 2102218443 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | 51 MED GP | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332000000X | Y | Suppliers | Military/U.S. Coast Guard Pharmacy |
No ID Information.