Provider Demographics
NPI:1265516470
Name:LAWRENCE JOEL ARMY HEALTH CLINIC
Entity type:Organization
Organization Name:LAWRENCE JOEL ARMY HEALTH CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:STAFF PHARMACIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:CARMEN
Authorized Official - Middle Name:RAKESTRAW
Authorized Official - Last Name:AGNEW
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:404-464-0304
Mailing Address - Street 1:2156 SPINK ST NW
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30318-1154
Mailing Address - Country:US
Mailing Address - Phone:404-792-5919
Mailing Address - Fax:
Practice Address - Street 1:1701 HARDEE AVE
Practice Address - Street 2:
Practice Address - City:FT MCPHERSON
Practice Address - State:GA
Practice Address - Zip Code:30330
Practice Address - Country:US
Practice Address - Phone:404-464-0304
Practice Address - Fax:404-464-0303
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA11620261QM1102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1102XAmbulatory Health Care FacilitiesClinic/CenterMilitary Outpatient Operational (Transportable) Component