Basic Information
| Provider Information | |||||||||
| NPI: | 1790092674 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | JAMES A LOVELL FEDERAL HEALTH CARE CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | NAVAL GREAT LAKES BURKEY MALL PHARMACY | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 322 | ||||||||
| Address2: | |||||||||
| City: | NORTH CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600640322 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8476881900 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2630 GREEN BAY RD | ||||||||
| Address2: | BLDG 3452 | ||||||||
| City: | GREAT LAKES | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600883303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8476881900 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2010 | ||||||||
| LastUpdateDate: | 09/21/2010 | ||||||||
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| AuthorizedOfficialLastName: | MAYERICK | ||||||||
| AuthorizedOfficialFirstName: | BARBARA | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR, BUSINESS DEVELOPMENT | ||||||||
| AuthorizedOfficialTelephone: | 2024611550 | ||||||||
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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 |
No ID Information.