Provider Demographics
NPI:1376642090
Name:316TH MEDICAL GROUP - MALCOLM GROW MEDICAL CENTER
Entity Type:Organization
Organization Name:316TH MEDICAL GROUP - MALCOLM GROW MEDICAL CENTER
Other - Org Name:BOLLING PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DHA FINANCIAL MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:CONDON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:240-401-3643
Mailing Address - Street 1:1060 W PERIMETER RD
Mailing Address - Street 2:
Mailing Address - City:JB ANDREWS
Mailing Address - State:MD
Mailing Address - Zip Code:20762-6602
Mailing Address - Country:US
Mailing Address - Phone:334-416-3921
Mailing Address - Fax:
Practice Address - Street 1:238 BROOKLEY AVE SW
Practice Address - Street 2:
Practice Address - City:BOLLING AFB
Practice Address - State:DC
Practice Address - Zip Code:20032-7704
Practice Address - Country:US
Practice Address - Phone:202-404-7742
Practice Address - Fax:703-614-1663
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:316TH MEDICAL GROUP - MALCOLM GROW MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-09-21
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332000000XSuppliersMilitary/U.S. Coast Guard Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2005908OtherPK