Basic Information
| Provider Information | |||||||||
| NPI: | 1841352358 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WALTER REED NATIONAL MILITARY MED CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | BETHESDA REFILL PHCY-VINSON HALL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8901 WISCONSIN AVE | ||||||||
| Address2: | PSC 509 CODE 6300 | ||||||||
| City: | BETHESDA | ||||||||
| State: | MD | ||||||||
| PostalCode: | 208895600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4102912123 | ||||||||
| FaxNumber: | 3012954662 | ||||||||
| Practice Location | |||||||||
| Address1: | 8901 WISCONSIN AVE | ||||||||
| Address2: | |||||||||
| City: | BETHESDA | ||||||||
| State: | MD | ||||||||
| PostalCode: | 208890004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4102912123 | ||||||||
| FaxNumber: | 3012954662 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/14/2006 | ||||||||
| LastUpdateDate: | 04/07/2016 | ||||||||
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| 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 | 2037273 | 01 | PK | OTHER |