Basic Information
| Provider Information | |||||||||
| NPI: | 1295793032 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | KANSAS CITY VAMC | ||||||||
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| OtherOrganizationName: | LEAVENWORTH VAMC PHARMACY | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 94458 | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441014458 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9135784409 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4101 S 4TH ST | ||||||||
| Address2: | |||||||||
| City: | LEAVENWORTH | ||||||||
| State: | KS | ||||||||
| PostalCode: | 660485014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7853503111 | ||||||||
| FaxNumber: | 7853504737 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/02/2006 | ||||||||
| LastUpdateDate: | 02/13/2019 | ||||||||
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| AuthorizedOfficialLastName: | POTTER | ||||||||
| AuthorizedOfficialFirstName: | ERIN | ||||||||
| AuthorizedOfficialMiddleName: | DENISE | ||||||||
| AuthorizedOfficialTitleorPosition: | NPI TEAM MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 2023822579 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336S0011X | N | Suppliers | Pharmacy | Specialty Pharmacy | 332100000X | Y | Suppliers | Department of Veterans Affairs (VA) Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 1712911 | 01 | KS | NCPDP# | OTHER |