Basic Information
| Provider Information | |||||||||
| NPI: | 1912313222 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | IRELAND ARMY COMMUNITY HOSPITAL | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | DOD ROCK ISLAND EPHCY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | IRELAND ARMY COMMUNITY HOSPITAL | ||||||||
| Address2: | TREASURERS OFFICE 289 IRELAND AVE | ||||||||
| City: | FORT KNOX | ||||||||
| State: | KY | ||||||||
| PostalCode: | 401215111 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3097820550 | ||||||||
| FaxNumber: | 3097820553 | ||||||||
| Practice Location | |||||||||
| Address1: | BLDG 110 RODMAN AVE. | ||||||||
| Address2: | |||||||||
| City: | ROCK ISLAND ARSENAL | ||||||||
| State: | IL | ||||||||
| PostalCode: | 612997240 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3097820550 | ||||||||
| FaxNumber: | 3097820553 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2014 | ||||||||
| LastUpdateDate: | 08/19/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MORALES | ||||||||
| AuthorizedOfficialFirstName: | HECTOR | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF DHA PASS | ||||||||
| AuthorizedOfficialTelephone: | 2105366650 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
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 | 2146682 | 01 | PK | OTHER |