Provider Demographics
NPI:1639938368
Name:KIMBROUGH ACC MILITARY MTF
Entity Type:Organization
Organization Name:KIMBROUGH ACC MILITARY MTF
Other - Org Name:
Other - Org Type:
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:RAVEN ROCK MOUNTAIN MEDICAL CLINIC 2A32
Mailing Address - Street 2:1155 DEFENSE PENTAGON
Mailing Address - City:WASHINGTON, DC
Mailing Address - State:DC
Mailing Address - Zip Code:20301-1155
Mailing Address - Country:US
Mailing Address - Phone:717-878-5252
Mailing Address - Fax:301-677-8456
Practice Address - Street 1:RAVEN ROCK MOUNTAIN COMPLEX
Practice Address - Street 2:450 HARBAUGH VALLEY ROAD
Practice Address - City:FAIRFIELD
Practice Address - State:PA
Practice Address - Zip Code:17214
Practice Address - Country:US
Practice Address - Phone:717-878-5252
Practice Address - Fax:301-677-8456
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KIMBROUGH ACC MILITARY MTF
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-03-15
Last Update Date:2024-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332000000XSuppliersMilitary/U.S. Coast Guard Pharmacy