Basic Information
| Provider Information | |||||||||
| NPI: | 1710252499 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NAVAL MEDICAL CENTER CAMP LEJEUNE | ||||||||
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| Mailing Information | |||||||||
| Address1: | PSC BOX 20117 | ||||||||
| Address2: | |||||||||
| City: | CAMP LEJEUNE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 285420117 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9104400011 | ||||||||
| FaxNumber: | 2102952567 | ||||||||
| Practice Location | |||||||||
| Address1: | A STREET | ||||||||
| Address2: | BLDG # RR 440 | ||||||||
| City: | CAMP LEJEUNE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 285420117 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9104400011 | ||||||||
| FaxNumber: | 9104401095 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/14/2012 | ||||||||
| LastUpdateDate: | 12/20/2017 | ||||||||
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| AuthorizedOfficialLastName: | CONDON | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | MICHAEL | ||||||||
| AuthorizedOfficialTitleorPosition: | NAVY MEDICINE UBO PROGRAM MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 2404013643 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | NAVAL MEDICAL CENTER CAMP LEJEUNE | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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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 | 2134220 | 01 | PK | OTHER |