Basic Information
| Provider Information | |||||||||
| NPI: | 1801195110 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | 92 MEDICAL GROUP/SGSL | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | FAIRCHILD ALT PHCY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 701 HOSPITAL LOOP | ||||||||
| Address2: | # 135 | ||||||||
| City: | FAIRCHILD AFB | ||||||||
| State: | WA | ||||||||
| PostalCode: | 990118704 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2102218443 | ||||||||
| FaxNumber: | 2102952567 | ||||||||
| Practice Location | |||||||||
| Address1: | 6955 22ND AVE NE | ||||||||
| Address2: | # 3401 | ||||||||
| City: | MOSES LAKE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 988373288 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5092471943 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/25/2011 | ||||||||
| LastUpdateDate: | 03/25/2011 | ||||||||
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| AuthorizedOfficialLastName: | MORALES | ||||||||
| AuthorizedOfficialFirstName: | HECTOR | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DEPUTY DIRECTOR OF PHARMAC Y OPS | ||||||||
| AuthorizedOfficialTelephone: | 2102218443 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | 92 MEDICAL GROUP/SGSL | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332000000X | Y | Suppliers | Military/U.S. Coast Guard Pharmacy |
No ID Information.