Provider Demographics
NPI:1821402652
Name:673RD MEDICAL GROUP JOINT BASE ELMENDORF-RICHARDSON
Entity Type:Organization
Organization Name:673RD MEDICAL GROUP JOINT BASE ELMENDORF-RICHARDSON
Other - Org Name:DOD FT RICHARDSON 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:210-221-8443
Mailing Address - Street 1:673RD MEDICAL GROUP JOINT BASE ELMENDORF-RICHARDSON
Mailing Address - Street 2:CO 673D MEDICAL GROUP SGSR 5955 ZEAMER AVE
Mailing Address - City:JBER
Mailing Address - State:AK
Mailing Address - Zip Code:99506-3702
Mailing Address - Country:US
Mailing Address - Phone:907-384-0610
Mailing Address - Fax:907-384-8195
Practice Address - Street 1:5955 ZEAMER AVE
Practice Address - Street 2:673RD MEDICAL GROUP
Practice Address - City:JBER
Practice Address - State:AK
Practice Address - Zip Code:99506-3702
Practice Address - Country:US
Practice Address - Phone:907-384-0610
Practice Address - Fax:907-384-8195
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-19
Last Update Date:2014-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332000000XSuppliersMilitary/U.S. Coast Guard Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2146326OtherPK