Provider Demographics
NPI:1508965831
Name:71TH MEDICAL GROUP SGSL
Entity Type:Organization
Organization Name:71TH MEDICAL GROUP SGSL
Other - Org Name:WRPAT KITTYHAWK 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:WRIGHT-PATTERSON MEDICAL CENTER
Mailing Address - Street 2:4881 SUGAR MAPLE DR
Mailing Address - City:WRIGHT PATTERSON
Mailing Address - State:OH
Mailing Address - Zip Code:45433-5546
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4881 SUGAR MAPLE DR
Practice Address - Street 2:BLDG 1250
Practice Address - City:WRIGHT PATTER
Practice Address - State:OH
Practice Address - Zip Code:45433-5529
Practice Address - Country:US
Practice Address - Phone:937-257-9028
Practice Address - Fax:937-656-2186
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-22
Last Update Date:2016-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332000000XSuppliersMilitary/U.S. Coast Guard Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2076528OtherPK