Basic Information
| Provider Information | |||||||||
| NPI: | 1306160973 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | 359TH MDG | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | RANDOLPH BX PHCY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 221 3RD ST W | ||||||||
| Address2: | BLDG 1040 | ||||||||
| City: | RANDOLPH AFB | ||||||||
| State: | TX | ||||||||
| PostalCode: | 781504800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2102218274 | ||||||||
| FaxNumber: | 2102952567 | ||||||||
| Practice Location | |||||||||
| Address1: | 630 3RD ST W | ||||||||
| Address2: | BLDG 1068 | ||||||||
| City: | RANDOLPH AFB | ||||||||
| State: | TX | ||||||||
| PostalCode: | 781504804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2106526742 | ||||||||
| FaxNumber: | 2106523516 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/25/2010 | ||||||||
| LastUpdateDate: | 10/24/2016 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MORALES | ||||||||
| AuthorizedOfficialFirstName: | HECTOR | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF DHA PASS | ||||||||
| AuthorizedOfficialTelephone: | 2105366650 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | |||||||||
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 | 2124452 | 01 | PK | OTHER |