Basic Information
| Provider Information | |||||||||
| NPI: | 1801039417 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | IRELAND ARMY COMMUNITY HOSPITAL | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | CAMP ATTERBURY PHCY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 289 IRELAND AVE | ||||||||
| Address2: | ATTN: TREASURER OFFICE | ||||||||
| City: | FORT KNOX | ||||||||
| State: | KY | ||||||||
| PostalCode: | 401215111 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5026249274 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | EVANS ROAD | ||||||||
| Address2: | BLDG 2 | ||||||||
| City: | CAMP ATTERBURY | ||||||||
| State: | IN | ||||||||
| PostalCode: | 461245000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8125261499 | ||||||||
| FaxNumber: | 8125261178 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/13/2009 | ||||||||
| LastUpdateDate: | 06/02/2015 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MORALES | ||||||||
| AuthorizedOfficialFirstName: | HECTOR | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF DHA PASS | ||||||||
| AuthorizedOfficialTelephone: | 2105366650 | ||||||||
| IsSoleProprietor: | |||||||||
| 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 | 2119981 | 01 | PK | OTHER |