Provider Demographics
NPI:1588764997
Name:EASTERN STATE HOSPITAL
Entity type:Organization
Organization Name:EASTERN STATE HOSPITAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:HOSPITAL DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:L
Authorized Official - Last Name:WOOD
Authorized Official - Suffix:
Authorized Official - Credentials:NHA
Authorized Official - Phone:757-253-5241
Mailing Address - Street 1:4601 IRONBOUND RD
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23188-2652
Mailing Address - Country:US
Mailing Address - Phone:757-253-5241
Mailing Address - Fax:757-253-5065
Practice Address - Street 1:4601 IRONBOUND RD
Practice Address - Street 2:
Practice Address - City:WILLIAMSBURG
Practice Address - State:VA
Practice Address - Zip Code:23188-2652
Practice Address - Country:US
Practice Address - Phone:757-253-5241
Practice Address - Fax:757-253-5065
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-25
Last Update Date:2010-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA004811659OtherMEDICARE PART D
VA0010230314Medicaid