Provider Demographics
NPI:1578979688
Name:90TH MEDICAL GROUP-UNITED STATES AIR FORCE
Entity Type:Organization
Organization Name:90TH MEDICAL GROUP-UNITED STATES AIR FORCE
Other - Org Name:DOD FE WARREN PHARMACY
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 1:90TH MEDICAL GROUP-UNITED STATES AIR FORCE
Mailing Address - Street 2:6900 ALDEN DR.
Mailing Address - City:FE WARREN AFB
Mailing Address - State:WY
Mailing Address - Zip Code:82005-3906
Mailing Address - Country:US
Mailing Address - Phone:307-773-3638
Mailing Address - Fax:307-773-4589
Practice Address - Street 1:6900 ALDEN DR BLDG 160
Practice Address - Street 2:
Practice Address - City:FE WARREN AFB
Practice Address - State:WY
Practice Address - Zip Code:82005-2945
Practice Address - Country:US
Practice Address - Phone:307-773-3638
Practice Address - Fax:307-773-3731
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-09
Last Update Date:2023-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332000000XSuppliersMilitary/U.S. Coast Guard Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2146759OtherPK