Provider Demographics
NPI:1275632317
Name:92ND MEDICAL GROUP
Entity Type:Organization
Organization Name:92ND MEDICAL GROUP
Other - Org Name:FAIRCHILD REFILL 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 1:92ND MEDICAL GROUP
Mailing Address - Street 2:RMO OFFICE 3RD PARTY COLLECTIONS 701 HOSPITAL LOOP
Mailing Address - City:FAIRCHILD AFB
Mailing Address - State:WA
Mailing Address - Zip Code:99011-8704
Mailing Address - Country:US
Mailing Address - Phone:509-247-2507
Mailing Address - Fax:509-247-5594
Practice Address - Street 1:BLDG 2460
Practice Address - Street 2:
Practice Address - City:FAIRCHILD AFB
Practice Address - State:WA
Practice Address - Zip Code:99011
Practice Address - Country:US
Practice Address - Phone:509-247-2507
Practice Address - Fax:509-247-5594
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-22
Last Update Date:2015-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332000000XSuppliersMilitary/U.S. Coast Guard Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2110606OtherPK