Basic Information
| Provider Information | |||||||||
| NPI: | 1801958806 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | KIMBROUGH ACC MILITARY MTF | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MEADE CIVILIAN RX PHCY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2480 LLEWELLYN AVE | ||||||||
| Address2: | CDR USAMEDDAC MCXR-BD STE 5800 | ||||||||
| City: | FT MEADE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 20755 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3016778512 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2480 LLEWELLYN AVE | ||||||||
| Address2: | |||||||||
| City: | FT MEADE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 20755 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3016778301 | ||||||||
| FaxNumber: | 3016197676 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/15/2006 | ||||||||
| LastUpdateDate: | 03/23/2011 | ||||||||
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| AuthorizedOfficialLastName: | MORALES | ||||||||
| AuthorizedOfficialFirstName: | HECTOR | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PHARMACY OPERATIONS CENTER MGR | ||||||||
| AuthorizedOfficialTelephone: | 2102218443 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | KIMBROUGH ACC MILITARY MTF | ||||||||
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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 | 2125804 | 01 | NCPDP | OTHER |