Basic Information
Provider Information | |||||||||
NPI: | 1265898670 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MONTGOMERY VAMC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | MONTGOMERY VA CLINIC PHARMACY | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 89470 | ||||||||
Address2: |   | ||||||||
City: | CLEVELAND | ||||||||
State: | OH | ||||||||
PostalCode: | 441016470 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8282572333 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 8105 VETERANS WAY | ||||||||
Address2: |   | ||||||||
City: | MONTGOMERY | ||||||||
State: | AL | ||||||||
PostalCode: | 361179998 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3342724670 | ||||||||
FaxNumber: | 3343952328 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/14/2016 | ||||||||
LastUpdateDate: | 11/10/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | POTTER | ||||||||
AuthorizedOfficialFirstName: | ERIN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | NPI TEAM MEMBER | ||||||||
AuthorizedOfficialTelephone: | 2023822579 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 11/10/2020 |
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 | 0141123 | 01 |   | NCPDP | OTHER |