Provider Demographics
NPI:1215036983
Name:EISENHOWER ARMY MEDICAL CENTER
Entity Type:Organization
Organization Name:EISENHOWER ARMY MEDICAL CENTER
Other - Org Name:FT EISENHOWER CONNELLY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DHA POD SR PROGRAM ANALYST
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:EISENHOWER ARMY MEDICAL CENTER
Mailing Address - Street 2:ATTN MCHF-PAD
Mailing Address - City:FT GORDON
Mailing Address - State:GA
Mailing Address - Zip Code:30905-5741
Mailing Address - Country:US
Mailing Address - Phone:706-787-5167
Mailing Address - Fax:706-787-6175
Practice Address - Street 1:AVENUE B BLDG 29709
Practice Address - Street 2:MARK CONNELLY HEALTH CLINIC
Practice Address - City:FT GORDON
Practice Address - State:GA
Practice Address - Zip Code:30905
Practice Address - Country:US
Practice Address - Phone:706-787-5167
Practice Address - Fax:706-787-6175
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2023-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332000000XSuppliersMilitary/U.S. Coast Guard Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2020249OtherPK