Provider Demographics
NPI:1295834448
Name:WILLFORD HALL MEDICAL CTR
Entity Type:Organization
Organization Name:WILLFORD HALL MEDICAL CTR
Other - Org Name:LACKLAND PC 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 1:2200 BERGQUIST DR STE 1
Mailing Address - Street 2:BLDG 4450
Mailing Address - City:LACKLAND AFB
Mailing Address - State:TX
Mailing Address - Zip Code:78236-9908
Mailing Address - Country:US
Mailing Address - Phone:210-292-7970
Mailing Address - Fax:210-292-3722
Practice Address - Street 1:2200 BERGQUIST DR STE 1
Practice Address - Street 2:BLDG 4450
Practice Address - City:LACKLAND AFB
Practice Address - State:TX
Practice Address - Zip Code:78236-9908
Practice Address - Country:US
Practice Address - Phone:210-292-7970
Practice Address - Fax:210-292-3722
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-22
Last Update Date:2016-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332000000XSuppliersMilitary/U.S. Coast Guard Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2093037OtherPK