Provider Demographics
NPI:1366856155
Name:355TH MEDICAL GROUP-DAVIS MONTHAN AFB HOSPITAL
Entity Type:Organization
Organization Name:355TH MEDICAL GROUP-DAVIS MONTHAN AFB HOSPITAL
Other - Org Name:DOD DAVIS MONTHAN PHARMACY
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 1:355TH MEDICAL GROUP-DAVIS MONTHAN AFB HOSPITAL C/O STAF
Mailing Address - Street 2:4175 S. ALAMO AVE.
Mailing Address - City:DM AFB
Mailing Address - State:AZ
Mailing Address - Zip Code:85707
Mailing Address - Country:US
Mailing Address - Phone:520-228-1924
Mailing Address - Fax:520-228-2853
Practice Address - Street 1:5405 E GRANITE ST
Practice Address - Street 2:BLDG # 2527 ROOM # 127
Practice Address - City:DAVIS MONTHAN AFB
Practice Address - State:AZ
Practice Address - Zip Code:85707-3004
Practice Address - Country:US
Practice Address - Phone:520-228-1924
Practice Address - Fax:520-228-2853
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-19
Last Update Date:2023-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332000000XSuppliersMilitary/U.S. Coast Guard Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2146402OtherPK