Provider Demographics
NPI:1801195110
Name:92 MEDICAL GROUP/SGSL
Entity Type:Organization
Organization Name:92 MEDICAL GROUP/SGSL
Other - Org Name:FAIRCHILD ALT PHCY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DEPUTY DIRECTOR OF PHARMAC Y OPS
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 1:701 HOSPITAL LOOP
Mailing Address - Street 2:# 135
Mailing Address - City:FAIRCHILD AFB
Mailing Address - State:WA
Mailing Address - Zip Code:99011-8704
Mailing Address - Country:US
Mailing Address - Phone:210-221-8443
Mailing Address - Fax:210-295-2567
Practice Address - Street 1:6955 22ND AVE NE
Practice Address - Street 2:# 3401
Practice Address - City:MOSES LAKE
Practice Address - State:WA
Practice Address - Zip Code:98837-3288
Practice Address - Country:US
Practice Address - Phone:509-247-1943
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:92 MEDICAL GROUP/SGSL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-03-25
Last Update Date:2011-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332000000XSuppliersMilitary/U.S. Coast Guard Pharmacy