Provider Demographics
NPI:1972602258
Name:4TH MEDICAL GROUP
Entity type:Organization
Organization Name:4TH MEDICAL GROUP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:NCOIC, UNIFORM BUSINESS OFFICE
Authorized Official - Prefix:
Authorized Official - First Name:TIFFANY
Authorized Official - Middle Name:
Authorized Official - Last Name:LIGHTHILL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-722-8257
Mailing Address - Street 1:2803 MEDICAL CAMPUS DRIVE
Mailing Address - Street 2:
Mailing Address - City:SEYMOUR JOHNSON AFB
Mailing Address - State:NC
Mailing Address - Zip Code:27531-2310
Mailing Address - Country:US
Mailing Address - Phone:919-722-8257
Mailing Address - Fax:
Practice Address - Street 1:2803 MEDICAL CAMPUS DRIVE
Practice Address - Street 2:
Practice Address - City:SEYMOUR JOHNSON AFB
Practice Address - State:NC
Practice Address - Zip Code:27531-2310
Practice Address - Country:US
Practice Address - Phone:919-722-8257
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-22
Last Update Date:2023-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332000000XSuppliersMilitary/U.S. Coast Guard Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2070465OtherPK