Healthcare Provider Details

I. General information

NPI: 1417287368
Provider Name (Legal Business Name): 121ST GENERAL HOSPITAL(BRAIN ALLGOOD ARMY COMMUNITY HOSPITAL)
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/28/2009
Last Update Date: 12/28/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

UNIT 15549 BOX 59
APO AP
96205-5549
US

IV. Provider business mailing address

DODDS-K SAHS UNIT 15549 BOX 59
APO AP
96205-5549
US

V. Phone/Fax

Practice location:
  • Phone: 82279173275
  • Fax: 82279176034
Mailing address:
  • Phone: 82279173275
  • Fax: 82279176034

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2865M2000X
TaxonomyMilitary General Acute Care Hospital
License Number0202202906
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code286500000X
TaxonomyMilitary Hospital
License Number0202202906
License Number StateVA

VIII. Authorized Official

Name: DORENE DENISE LUKE-WALTON
Title or Position: PHARMACIST/PYXIS ADMINISTRATOR
Credential:
Phone: 82279173275