Basic Information
| Provider Information | |||||||||
| NPI: | 1912310772 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WOMACK ARMY MEDICAL CENTER | ||||||||
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| OtherOrganizationName: | DOD FT BRAGG EPHCY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | WOMACK ARMY MEDICAL CTR | ||||||||
| Address2: | MCXC-DBO- WAMC STOP ABUILDING 4-2817 REILLY ROAD | ||||||||
| City: | FORT BRAGG | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283105000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9109077497 | ||||||||
| FaxNumber: | 9105703371 | ||||||||
| Practice Location | |||||||||
| Address1: | WOMACK ARMY MEDICAL CTR | ||||||||
| Address2: | BUILDING 4-2817 REILLY ROAD | ||||||||
| City: | FORT BRAGG | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283105000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9109077497 | ||||||||
| FaxNumber: | 9105703371 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2014 | ||||||||
| LastUpdateDate: | 01/28/2016 | ||||||||
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| AuthorizedOfficialLastName: | MORALES | ||||||||
| AuthorizedOfficialFirstName: | HECTOR | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF DHA PASS | ||||||||
| AuthorizedOfficialTelephone: | 2105366650 | ||||||||
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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 |
ID Information
| ID | Type | State | Issuer | Description | 2145980 | 01 | PK | OTHER |