Healthcare Provider Details

I. General information

NPI: 1346302403
Provider Name (Legal Business Name): QUANTICO SPECIAL ORDER PHCY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/15/2006
Last Update Date: 08/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

NMC 2200 LESTER AVENUE
QUANTICO VA
22134
US

IV. Provider business mailing address

NMC 2200 LESTER AVENUE
QUANTICO VA
22134
US

V. Phone/Fax

Practice location:
  • Phone: 703-784-1579
  • Fax: 703-784-1579
Mailing address:
  • Phone: 703-784-1579
  • Fax: 703-784-1579

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332000000X
TaxonomyMilitary/U.S. Coast Guard Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: HECTOR MORALES
Title or Position: PHARMACY OPERATIONS CENTER MGR
Credential:
Phone: 210-221-8443