Provider Demographics
NPI:1083012223
Name:96TH MEDICAL SUPPORT SQUADRON
Entity Type:Organization
Organization Name:96TH MEDICAL SUPPORT SQUADRON
Other - Org Name:EGLIN 7TH SFG PHCY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF DHA PASS
Authorized Official - Prefix:
Authorized Official - First Name:HECTOR
Authorized Official - Middle Name:
Authorized Official - Last Name:MORALES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:210-536-6650
Mailing Address - Street 1:307 BOATNER RD STE 114
Mailing Address - Street 2:
Mailing Address - City:EGLIN AFB
Mailing Address - State:FL
Mailing Address - Zip Code:32542-1302
Mailing Address - Country:US
Mailing Address - Phone:850-885-7554
Mailing Address - Fax:850-885-9977
Practice Address - Street 1:4315 EL SALVADOR WAY
Practice Address - Street 2:BUILDING 4315
Practice Address - City:EGLIN AFB
Practice Address - State:FL
Practice Address - Zip Code:32542-1711
Practice Address - Country:US
Practice Address - Phone:850-885-7554
Practice Address - Fax:850-885-9977
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-19
Last Update Date:2016-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332000000XSuppliersMilitary/U.S. Coast Guard Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2149365OtherPK