Provider Demographics
NPI:1558760504
Name:14TH MEDICAL SQUADRON
Entity Type:Organization
Organization Name:14TH MEDICAL SQUADRON
Other - Org Name:DOD COLUMBUS EPHCY
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 1:14TH MEDICAL SQUADRON
Mailing Address - Street 2:201 INDEPENDENCE DR.
Mailing Address - City:COLUMBUS AFB
Mailing Address - State:MS
Mailing Address - Zip Code:39710
Mailing Address - Country:US
Mailing Address - Phone:662-434-2168
Mailing Address - Fax:662-434-2169
Practice Address - Street 1:201 INDEPENDENCE BLDG 1100
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:MS
Practice Address - Zip Code:39710-5300
Practice Address - Country:US
Practice Address - Phone:662-434-2168
Practice Address - Fax:662-434-2169
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-15
Last Update Date:2016-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332000000XSuppliersMilitary/U.S. Coast Guard Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2147338OtherPK