Basic Information
| Provider Information | |||||||||
| NPI: | 1861800567 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | 359 MEDICAL GROUP | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | DOD RANDOLPH BX EPHCY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 359 MEDICAL GROUP C/O 359 MDSS RESOURCE MANAGEMENT OFFI | ||||||||
| Address2: | 221 3RD ST. W | ||||||||
| City: | RANDOLPH AFB | ||||||||
| State: | TX | ||||||||
| PostalCode: | 78150 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2106524189 | ||||||||
| FaxNumber: | 2106523516 | ||||||||
| Practice Location | |||||||||
| Address1: | 221 3RD ST W BLDG 1040 | ||||||||
| Address2: | |||||||||
| City: | RANDOLPH AFB | ||||||||
| State: | TX | ||||||||
| PostalCode: | 781504800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2106524189 | ||||||||
| FaxNumber: | 2106523516 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/25/2014 | ||||||||
| LastUpdateDate: | 08/18/2015 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MORALES | ||||||||
| AuthorizedOfficialFirstName: | HECTOR | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF DHA PASS | ||||||||
| AuthorizedOfficialTelephone: | 2105366650 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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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 | 2147027 | 01 | PK | OTHER |