Basic Information
| Provider Information | |||||||||
| NPI: | 1255389730 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MONTGOMERY VAMC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | TUSKEGEE VAMC PHARMACY | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 89470 | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441016470 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8282572333 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2400 HOSPITAL ROAD | ||||||||
| Address2: | |||||||||
| City: | TUSKEGEE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 360835001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3347270550 | ||||||||
| FaxNumber: | 3347252569 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/05/2006 | ||||||||
| LastUpdateDate: | 01/08/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | POTTER | ||||||||
| AuthorizedOfficialFirstName: | ERIN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | NPI TEAM MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 2023822579 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332100000X | Y | Suppliers | Department of Veterans Affairs (VA) Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 0132667 | 01 | AL | NCPDP# | OTHER |