Provider Demographics
NPI:1598177370
Name:DEPARTMENT OF DEFENSE-AIR FORCE
Entity Type:Organization
Organization Name:DEPARTMENT OF DEFENSE-AIR FORCE
Other - Org Name:DOD ALTUS 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 1:97 MDG MSC FUND C/O MSC TREASURER
Mailing Address - Street 2:TSG MARIA DELEON 301 N FIRST ST. BLDG 46
Mailing Address - City:ALTUS AFB
Mailing Address - State:OK
Mailing Address - Zip Code:73523
Mailing Address - Country:US
Mailing Address - Phone:580-481-5258
Mailing Address - Fax:
Practice Address - Street 1:301 N 1ST ST
Practice Address - Street 2:BLDG 46
Practice Address - City:ALTUS AFB
Practice Address - State:OK
Practice Address - Zip Code:73523-5004
Practice Address - Country:US
Practice Address - Phone:580-481-5258
Practice Address - Fax:580-481-7420
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-28
Last Update Date:2017-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332000000XSuppliersMilitary/U.S. Coast Guard Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2145934OtherPK