Basic Information
Provider Information | |||||||||
NPI: | 1902084577 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | NAVAL HEALTH CLINIC HAWAII | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | TRIPLER ARMY MEDICAL CENTER | ||||||||
Address2: | PAD (MCHK-PAT-T) 1 JARRETT WHITE RD | ||||||||
City: | HONOLULU | ||||||||
State: | HI | ||||||||
PostalCode: | 968595001 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: |   | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | WAHAIWA BRMAX EASTPAC | ||||||||
Address2: | 500 CENTER ST BLDG 22 | ||||||||
City: | WAHIAWA | ||||||||
State: | HI | ||||||||
PostalCode: | 96786 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8084731880 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/06/2008 | ||||||||
LastUpdateDate: | 12/19/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | CONDON | ||||||||
AuthorizedOfficialFirstName: | WILLIAM | ||||||||
AuthorizedOfficialMiddleName: | MICHAEL | ||||||||
AuthorizedOfficialTitleorPosition: | NAVY MEDICINE UBO PROGRAM MANAGER | ||||||||
AuthorizedOfficialTelephone: | 2404013643 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | NAVAL HEALTH CLINIC HAWAII | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
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 | 2019346 | 01 |   | PK | OTHER |