Provider Demographics
NPI:1881009033
Name:20TH MEDICAL SUPPORT SQUADRON
Entity Type:Organization
Organization Name:20TH MEDICAL SUPPORT SQUADRON
Other - Org Name:DOD SHAW 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 1:20TH MEDICAL SUPPORT SQUADRON US AIR FORCE HOSPITAL
Mailing Address - Street 2:431 MEADOWLARK ST
Mailing Address - City:SHAW AFB
Mailing Address - State:SC
Mailing Address - Zip Code:29152
Mailing Address - Country:US
Mailing Address - Phone:803-895-1309
Mailing Address - Fax:803-895-6463
Practice Address - Street 1:431 MEADOWLARK ST
Practice Address - Street 2:
Practice Address - City:SHAW AFB
Practice Address - State:SC
Practice Address - Zip Code:29152-5019
Practice Address - Country:US
Practice Address - Phone:803-895-1309
Practice Address - Fax:803-895-6463
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-26
Last Update Date:2016-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332000000XSuppliersMilitary/U.S. Coast Guard Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2146551OtherPK