Provider Demographics
NPI:1609120005
Name:NAVAL MEDICAL CENTER SAN DIEGO
Entity Type:Organization
Organization Name:NAVAL MEDICAL CENTER SAN DIEGO
Other - Org Name:SAN DG EASTLAKE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF DHA POSC
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 1:34520 BOB WILSON DR
Mailing Address - Street 2:SUITE 20
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92134-2098
Mailing Address - Country:US
Mailing Address - Phone:619-532-8407
Mailing Address - Fax:619-532-6260
Practice Address - Street 1:2300 BOSWELL RD
Practice Address - Street 2:SUITE 190
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91914-3523
Practice Address - Country:US
Practice Address - Phone:619-532-8407
Practice Address - Fax:619-532-6260
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NAVAL MEDICAL CENTER SAN DIEGO
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-11-07
Last Update Date:2023-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332000000XSuppliersMilitary/U.S. Coast Guard Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2137762OtherPK