1184796690 NPI number — GOVERNMENT OF GUAM DEPARTMENT OF ADMINISTRATION

Table of content: (NPI 1184796690)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184796690 NPI number — GOVERNMENT OF GUAM DEPARTMENT OF ADMINISTRATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GOVERNMENT OF GUAM DEPARTMENT OF ADMINISTRATION
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
SOUTHERN REGION COMMUNITY HEALTH CENTER PHARMACY (SRCHC)
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1184796690
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/28/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
123 CHALAN KARETA
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MANGILAO
Provider Business Mailing Address State Name:
GU
Provider Business Mailing Address Postal Code:
96913-6304
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
162 AS ABMAN DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
INARAJAN
Provider Business Practice Location Address State Name:
GU
Provider Business Practice Location Address Postal Code:
96917
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
671-828-7547
Provider Business Practice Location Address Fax Number:
671-828-7504
Provider Enumeration Date:
11/14/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DELOSO
Authorized Official First Name:
MICHELLE
Authorized Official Middle Name:
Authorized Official Title or Position:
PHARMACY MANAGER
Authorized Official Telephone Number:
671-635-7447

Provider Taxonomy Codes

  • Taxonomy code: 3336C0002X , with the licence number:  PCY011 , registered in the state of GU ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336C0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 636 , issued by the state of ( GU ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2112062 . This is a "PK" identifier . This identifiers is of the category "OTHER".




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