Provider Demographics
NPI:1598862344
Name:359TH MDG
Entity Type:Organization
Organization Name:359TH MDG
Other - Org Name:RANDOLPH PHCY
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 1:221 3RD ST W BLDG 1040
Mailing Address - Street 2:
Mailing Address - City:UNIVERSAL CITY
Mailing Address - State:TX
Mailing Address - Zip Code:78150-4800
Mailing Address - Country:US
Mailing Address - Phone:210-652-4127
Mailing Address - Fax:210-652-3516
Practice Address - Street 1:221 3RD ST W BLDG 1040
Practice Address - Street 2:
Practice Address - City:UNIVERSAL CITY
Practice Address - State:TX
Practice Address - Zip Code:78150-4800
Practice Address - Country:US
Practice Address - Phone:210-652-4127
Practice Address - Fax:210-652-3516
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2016-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332000000XSuppliersMilitary/U.S. Coast Guard Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2093375OtherPK