Provider Demographics
NPI:1841606936
Name:19TH MDSS SGSR
Entity Type:Organization
Organization Name:19TH MDSS SGSR
Other - Org Name:DOD LITTLE ROCK 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 1:19TH MDSS SGSR C/O MARTHA BLAND
Mailing Address - Street 2:1090 ARNOLD DR.
Mailing Address - City:LR AFB
Mailing Address - State:AR
Mailing Address - Zip Code:72099-4933
Mailing Address - Country:US
Mailing Address - Phone:501-987-7446
Mailing Address - Fax:501-987-7605
Practice Address - Street 1:1090 ARNOLD DR
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK AFB
Practice Address - State:AR
Practice Address - Zip Code:72099-4933
Practice Address - Country:US
Practice Address - Phone:501-987-7446
Practice Address - Fax:501-987-8786
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-09
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332000000XSuppliersMilitary/U.S. Coast Guard Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2146756OtherPK