Provider Demographics
NPI:1336203082
Name:KIMBROUGH ACC MILITARY MTF
Entity Type:Organization
Organization Name:KIMBROUGH ACC MILITARY MTF
Other - Org Name:CARLISLE DUNHAM ATA PHCY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER PHARMACY OPERATIONS CENTER
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:210-221-8443
Mailing Address - Street 1:2480 LLEWELLYN AVE
Mailing Address - Street 2:CDR USAMEDDAC MCXR-BD STE 5800
Mailing Address - City:FORT MEADE
Mailing Address - State:MD
Mailing Address - Zip Code:20755-7081
Mailing Address - Country:US
Mailing Address - Phone:301-677-8512
Mailing Address - Fax:
Practice Address - Street 1:450 GIBNER RD
Practice Address - Street 2:CARLISLE DUNHAM ATA PHCY
Practice Address - City:CARLISLE BARRACKS
Practice Address - State:PA
Practice Address - Zip Code:17013-5090
Practice Address - Country:US
Practice Address - Phone:702-653-3205
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KIMBROUGH ACC MILITARY MTF
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-12-20
Last Update Date:2011-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332000000XSuppliersMilitary/U.S. Coast Guard Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
3979133OtherNCPDP