Provider Demographics
NPI:1982686036
Name:DEPARTMENT OF VETERANS AFFAIRS
Entity Type:Organization
Organization Name:DEPARTMENT OF VETERANS AFFAIRS
Other - Org Name:VA OUTPATIENT CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF PHARMACIST
Authorized Official - Prefix:DR
Authorized Official - First Name:FEACHER
Authorized Official - Middle Name:LEROY
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:JR
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:904-232-2751
Mailing Address - Street 1:1833 BOULEVARD
Mailing Address - Street 2:SUITE A
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32206-4382
Mailing Address - Country:US
Mailing Address - Phone:904-232-2751
Mailing Address - Fax:904-232-1570
Practice Address - Street 1:1833 BOULEVARD
Practice Address - Street 2:SUITE A
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32206-4382
Practice Address - Country:US
Practice Address - Phone:904-232-2751
Practice Address - Fax:904-232-1570
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL12760261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center