Provider Demographics
NPI:1417287368
Name:121ST GENERAL HOSPITAL(BRAIN ALLGOOD ARMY COMMUNITY HOSPITAL)
Entity Type:Organization
Organization Name:121ST GENERAL HOSPITAL(BRAIN ALLGOOD ARMY COMMUNITY HOSPITAL)
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST/PYXIS ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DORENE
Authorized Official - Middle Name:DENISE
Authorized Official - Last Name:LUKE-WALTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:8227-917-3275
Mailing Address - Street 1:DODDS-K SAHS
Mailing Address - Street 2:UNIT 15549 BOX 59
Mailing Address - City:APO
Mailing Address - State:AP
Mailing Address - Zip Code:96205-5549
Mailing Address - Country:US
Mailing Address - Phone:8227-917-3275
Mailing Address - Fax:8227-917-6034
Practice Address - Street 1:UNIT 15549 BOX 59
Practice Address - Street 2:
Practice Address - City:APO
Practice Address - State:AP
Practice Address - Zip Code:96205-5549
Practice Address - Country:US
Practice Address - Phone:8227-917-3275
Practice Address - Fax:8227-917-6034
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-28
Last Update Date:2009-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202202906286500000X, 2865M2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes286500000XHospitalsMilitary Hospital
No2865M2000XHospitalsMilitary HospitalMilitary General Acute Care Hospital