Provider Demographics
NPI:1164507703
Name:FT MEADE MEDDAC
Entity type:Organization
Organization Name:FT MEADE MEDDAC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:UBO MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TERRI
Authorized Official - Middle Name:
Authorized Official - Last Name:KIMBROW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-677-8512
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:301-677-8800
Mailing Address - Fax:
Practice Address - Street 1:2480 LLEWELLYN AVE
Practice Address - Street 2:
Practice Address - City:FORT MEADE
Practice Address - State:MD
Practice Address - Zip Code:20755-5800
Practice Address - Country:US
Practice Address - Phone:301-677-8800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FT MEADE MEDDAC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-25
Last Update Date:2025-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1101XAmbulatory Health Care FacilitiesClinic/CenterMilitary and U.S. Coast Guard Ambulatory Procedure
No261QM1100XAmbulatory Health Care FacilitiesClinic/CenterMilitary/U.S. Coast Guard Outpatient
No332000000XSuppliersMilitary/U.S. Coast Guard Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AN2598588OtherMEDCO
02DTOtherBCBS FEDERAL
1447357298 / 2125284OtherPHARMACY NPI/NCPDP
AN2598588OtherMEDCO
VAD000Medicare UPIN