Provider Demographics
NPI:1639403090
Name:22ND MEDGP/SGSLA
Entity Type:Organization
Organization Name:22ND MEDGP/SGSLA
Other - Org Name:MCCONNEL SPO PHCY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DEPUTY DIRECTOR OF PHARMACY OPS CTR
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:210-221-8443
Mailing Address - Street 1:2450 STANLEY RD STE 208
Mailing Address - Street 2:
Mailing Address - City:FORT SAM HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:78234-6108
Mailing Address - Country:US
Mailing Address - Phone:210-221-8274
Mailing Address - Fax:210-285-2567
Practice Address - Street 1:57950 LEAVENWORTH ST
Practice Address - Street 2:
Practice Address - City:MCCONNELL AFB
Practice Address - State:KS
Practice Address - Zip Code:67221-3506
Practice Address - Country:US
Practice Address - Phone:316-759-4203
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:22ND MEDGP/SGSLA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-10-01
Last Update Date:2009-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332000000XSuppliersMilitary/U.S. Coast Guard Pharmacy