Provider Demographics
NPI:1396181533
Name:341ST MEDICAL GROUP
Entity Type:Organization
Organization Name:341ST MEDICAL GROUP
Other - Org Name:MALSTROM REFILL PHCY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DEPUTY DIRECTOR PHCY OPS CTR
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:210-221-8443
Mailing Address - Street 1:341 MDG/MDSS/SGSA 7300 N PERIMETER RD
Mailing Address - Street 2:BLDG 2040
Mailing Address - City:MALSTROM AFB
Mailing Address - State:MT
Mailing Address - Zip Code:59402
Mailing Address - Country:US
Mailing Address - Phone:406-731-2468
Mailing Address - Fax:
Practice Address - Street 1:341 MDG/MDSS/SGSA 7300 N PERIMETER RD
Practice Address - Street 2:BLDG 2040
Practice Address - City:MALSTROM AFB
Practice Address - State:MT
Practice Address - Zip Code:59402
Practice Address - Country:US
Practice Address - Phone:406-731-2468
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-15
Last Update Date:2013-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332000000XSuppliersMilitary/U.S. Coast Guard Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2140376OtherPK