Provider Demographics
NPI:1659547800
Name:FAYETTEVILLE VAMC
Entity Type:Organization
Organization Name:FAYETTEVILLE VAMC
Other - Org Name:SPRINGFIELD MO VA CLINIC PHARMACY
Other - Org Type:Other Name
Authorized Official - Title/Position:NPI TEAM MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:ERIN
Authorized Official - Middle Name:
Authorized Official - Last Name:POTTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:202-382-2579
Mailing Address - Street 1:PO BOX 94494
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44101
Mailing Address - Country:US
Mailing Address - Phone:615-355-3451
Mailing Address - Fax:
Practice Address - Street 1:1850 WEST REPUBLIC RD
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-5730
Practice Address - Country:US
Practice Address - Phone:479-587-5912
Practice Address - Fax:479-587-5875
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-07
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332100000XSuppliersDepartment of Veterans Affairs (VA) Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2636263OtherNCPDP