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? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 332000000X | Suppliers | Military/U.S. Coast Guard Pharmacy |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
2093375 | Other | PK |