Provider Demographics
NPI:1598177123
Name:96TH MEDICAL SUPPORT SQUADRON
Entity Type:Organization
Organization Name:96TH MEDICAL SUPPORT SQUADRON
Other - Org Name:DOD EGLIN 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 1:96 MEDICAL SUPPORT SQUADRON
Mailing Address - Street 2:307 BOATNER RD. STE 114
Mailing Address - City:EGLIN AFB
Mailing Address - State:FL
Mailing Address - Zip Code:32542-1302
Mailing Address - Country:US
Mailing Address - Phone:850-883-8000
Mailing Address - Fax:850-883-9322
Practice Address - Street 1:96 MEDICAL GROUP SATELLITE PHCY MEMORIAL TRAIL
Practice Address - Street 2:BLDG. 1758
Practice Address - City:EGLIN AFB
Practice Address - State:FL
Practice Address - Zip Code:32542
Practice Address - Country:US
Practice Address - Phone:850-883-8000
Practice Address - Fax:850-883-9131
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-02
Last Update Date:2016-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332000000XSuppliersMilitary/U.S. Coast Guard Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2146012OtherPK