Provider Demographics
NPI:1578762175
Name:SAN DG SAN CLEMENTE PHCY
Entity Type:Organization
Organization Name:SAN DG SAN CLEMENTE PHCY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER DOD PHARMACY OPERATIONS CEN
Authorized Official - Prefix:MR
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 1:2450 STANLEY RD
Mailing Address - Street 2:SUITE 208
Mailing Address - City:FORT SAM HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:78234-7510
Mailing Address - Country:US
Mailing Address - Phone:210-221-8274
Mailing Address - Fax:
Practice Address - Street 1:BRANCH MEDICAL CLINIC
Practice Address - Street 2:BLDG 60126
Practice Address - City:SAN CLEMENTE ISLAND
Practice Address - State:CA
Practice Address - Zip Code:92135
Practice Address - Country:US
Practice Address - Phone:619-524-9356
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-13
Last Update Date:2007-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332000000XSuppliersMilitary/U.S. Coast Guard Pharmacy