Basic Information
| Provider Information | |||||||||
| NPI: | 1134397037 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NAVAL HEALTH CLINIC HAWAII | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2450 STANLEY RD | ||||||||
| Address2: | SUITE 208 | ||||||||
| City: | FORT SAM HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782347510 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2102218443 | ||||||||
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| Practice Location | |||||||||
| Address1: | CAMP SMITH MEDICAL NAVAL ANNEX | ||||||||
| Address2: | |||||||||
| City: | CAMP SMITH | ||||||||
| State: | HI | ||||||||
| PostalCode: | 96861 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8084731880 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/13/2008 | ||||||||
| LastUpdateDate: | 12/19/2017 | ||||||||
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| AuthorizedOfficialLastName: | CONDON | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | MICHAEL | ||||||||
| AuthorizedOfficialTitleorPosition: | NAVY MEDICINE UBO PROGRAM MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 2404013643 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | NAVAL HEALTH CLINIC HAWAII | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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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 | 1204267 | 01 | NCPDP | OTHER |