Provider Demographics
NPI:1164584397
Name:GAHCC-TPCP
Entity Type:Organization
Organization Name:GAHCC-TPCP
Other - Org Name:NORTH RIVA RIDGE MED ROOM PHCY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF DHA PASS
Authorized Official - Prefix:
Authorized Official - First Name:HECTOR
Authorized Official - Middle Name:
Authorized Official - Last Name:MORALES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:210-536-6650
Mailing Address - Street 1:10205 N RIVA RIDGE LOOP
Mailing Address - Street 2:
Mailing Address - City:FORT DRUM
Mailing Address - State:NY
Mailing Address - Zip Code:13602-5457
Mailing Address - Country:US
Mailing Address - Phone:315-772-8860
Mailing Address - Fax:
Practice Address - Street 1:10205 N RIVA RIDGE LOOP
Practice Address - Street 2:
Practice Address - City:FORT DRUM
Practice Address - State:NY
Practice Address - Zip Code:13602-5457
Practice Address - Country:US
Practice Address - Phone:315-772-8860
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-14
Last Update Date:2016-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332000000XSuppliersMilitary/U.S. Coast Guard Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2057270OtherPK
1730247156OtherPARENT BILLING NPI