Basic Information
| Provider Information | |||||||||
| NPI: | 1225137342 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WILLFORD HALL MEDICAL CTR | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | DOD POD EPHCY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2200 BERGQUIST DR STE 1 | ||||||||
| Address2: | |||||||||
| City: | LACKLAND AFB | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782369908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2105366650 | ||||||||
| FaxNumber: | 2106703722 | ||||||||
| Practice Location | |||||||||
| Address1: | 2200 BERGQUIST DR STE 1 | ||||||||
| Address2: | |||||||||
| City: | LACKLAND AFB | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782369908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2102925410 | ||||||||
| FaxNumber: | 2106703722 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/22/2006 | ||||||||
| LastUpdateDate: | 08/20/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MORALES | ||||||||
| AuthorizedOfficialFirstName: | HECTOR | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF DHA PASS | ||||||||
| AuthorizedOfficialTelephone: | 2105366650 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/20/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332000000X | Y | Suppliers | Military/U.S. Coast Guard Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 2105569 | 01 | PK | OTHER |