Provider Demographics
NPI:1619381415
Name:DEPARTMENT OF AIR FORCE 81ST MEDICAL GROUP
Entity Type:Organization
Organization Name:DEPARTMENT OF AIR FORCE 81ST MEDICAL GROUP
Other - Org Name:DOD KEESLER 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:DEPARTMENT OF AIR FORCE 81ST MEDICAL GROUP
Mailing Address - Street 2:301 FISHER ST. STE 104
Mailing Address - City:KEESLER AFB
Mailing Address - State:MS
Mailing Address - Zip Code:39534-2517
Mailing Address - Country:US
Mailing Address - Phone:228-376-0058
Mailing Address - Fax:228-377-6582
Practice Address - Street 1:506 LARCHER BLVD STE B
Practice Address - Street 2:
Practice Address - City:KEESLER AFB
Practice Address - State:MS
Practice Address - Zip Code:39534-2342
Practice Address - Country:US
Practice Address - Phone:228-377-6585
Practice Address - Fax:228-376-0058
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-19
Last Update Date:2015-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332000000XSuppliersMilitary/U.S. Coast Guard Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2146417OtherPK