Provider Demographics
NPI:1497854566
Name:42ND MEDICAL GROUP SGSL
Entity Type:Organization
Organization Name:42ND MEDICAL GROUP SGSL
Other - Org Name:MAXWELL GUNTER 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:BLDG 810 GUNTER ANNEX
Mailing Address - Street 2:
Mailing Address - City:MAXWELL AFB
Mailing Address - State:AL
Mailing Address - Zip Code:36112
Mailing Address - Country:US
Mailing Address - Phone:334-416-5455
Mailing Address - Fax:334-953-1505
Practice Address - Street 1:BLDG 810 GUNTER ANNEX
Practice Address - Street 2:
Practice Address - City:MAXWELL AFB
Practice Address - State:AL
Practice Address - Zip Code:36112
Practice Address - Country:US
Practice Address - Phone:334-416-5455
Practice Address - Fax:334-953-1505
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-22
Last Update Date:2016-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332000000XSuppliersMilitary/U.S. Coast Guard Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1994587OtherPK