Basic Information
| Provider Information | |||||||||
| NPI: | 1215345087 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GULF COAST VETERANS HEALTH CARE SYSTEM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 400 VETERANS AVE | ||||||||
| Address2: | |||||||||
| City: | BILOXI | ||||||||
| State: | MS | ||||||||
| PostalCode: | 395312410 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2285235000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 400 VETERANS AVE | ||||||||
| Address2: | |||||||||
| City: | BILOXI | ||||||||
| State: | MS | ||||||||
| PostalCode: | 395312410 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2285235000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/24/2014 | ||||||||
| LastUpdateDate: | 07/24/2014 | ||||||||
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| AuthorizedOfficialLastName: | RILEY | ||||||||
| AuthorizedOfficialFirstName: | NICOLE | ||||||||
| AuthorizedOfficialMiddleName: | LYNN | ||||||||
| AuthorizedOfficialTitleorPosition: | PHARMACIST | ||||||||
| AuthorizedOfficialTelephone: | 5044212820 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | PHARM.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QV0200X | PST.020646 | LA | Y | Ambulatory Health Care Facilities | Clinic/Center | VA |
No ID Information.