Provider Demographics
NPI:1356027429
Name:121ST CSH/BAACH
Entity type:Organization
Organization Name:121ST CSH/BAACH
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MTF SUPPORT
Authorized Official - Prefix:
Authorized Official - First Name:ROSEMARY
Authorized Official - Middle Name:
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:210-536-6650
Mailing Address - Street 1:USGA-HUMPHREYS
Mailing Address - Street 2:BLDG. 6370
Mailing Address - City:CAMP HUMPHREYS
Mailing Address - State:SOUTH KOREA
Mailing Address - Zip Code:96271
Mailing Address - Country:KP
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:USGA-HUMPHREYS
Practice Address - Street 2:BLDG. 6370
Practice Address - City:CAMP HUMPHREYS
Practice Address - State:SOUTH KOREA
Practice Address - Zip Code:96271
Practice Address - Country:KP
Practice Address - Phone:210-536-6650
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:121ST CSH/BAACH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-06-23
Last Update Date:2023-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332000000XSuppliersMilitary/U.S. Coast Guard Pharmacy