Provider Demographics
NPI:1679672083
Name:DUNHAM ARMY HEALTH CLINIC
Entity Type:Organization
Organization Name:DUNHAM ARMY HEALTH CLINIC
Other - Org Name:DETRICK 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 1:1452 PORTER ST
Mailing Address - Street 2:2480 LLEWELLYN AVE STE 5800
Mailing Address - City:FT DETRICK
Mailing Address - State:MD
Mailing Address - Zip Code:21702
Mailing Address - Country:US
Mailing Address - Phone:301-619-2850
Mailing Address - Fax:301-619-7676
Practice Address - Street 1:1452 PORTER ST
Practice Address - Street 2:
Practice Address - City:FT DETRICK
Practice Address - State:MD
Practice Address - Zip Code:21702
Practice Address - Country:US
Practice Address - Phone:301-619-2850
Practice Address - Fax:301-619-7676
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-22
Last Update Date:2015-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332000000XSuppliersMilitary/U.S. Coast Guard Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2037183OtherPK
1649296815OtherFACILITY NPI - BARQUIST AHC
2125361OtherOTHER ID NUMBER-COMMERCIAL NUMBER
005640OtherPAYMENT CENTER ID