Basic Information
| Provider Information | |||||||||
| NPI: | 1619403748 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GLWACH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 118A EDNA | ||||||||
| Address2: | |||||||||
| City: | WAYNESVILLE | ||||||||
| State: | MO | ||||||||
| PostalCode: | 655837875 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3146005329 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4430 MISSOURI AVE | ||||||||
| Address2: | GLWACH | ||||||||
| City: | FORT LEONARD WOOD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 654739098 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5735960515 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/10/2017 | ||||||||
| LastUpdateDate: | 05/10/2017 | ||||||||
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| AuthorizedOfficialLastName: | UDE | ||||||||
| AuthorizedOfficialFirstName: | UDE | ||||||||
| AuthorizedOfficialMiddleName: | U | ||||||||
| AuthorizedOfficialTitleorPosition: | PHARMACIST | ||||||||
| AuthorizedOfficialTelephone: | 31456005329 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | PHARMD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 286500000X | 2013031924 | MO | Y | Hospitals | Military Hospital |
No ID Information.