Provider Demographics
NPI:1962818336
Name:71 MDG MDSS SGSR
Entity Type:Organization
Organization Name:71 MDG MDSS SGSR
Other - Org Name:DOD VANCE 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 1:71 MDG MDSS SGSR C/O 71 MDG MDSS SGSR
Mailing Address - Street 2:527 GOTT RD
Mailing Address - City:ENID
Mailing Address - State:OK
Mailing Address - Zip Code:73705
Mailing Address - Country:US
Mailing Address - Phone:580-213-7455
Mailing Address - Fax:580-213-2169
Practice Address - Street 1:527 GOTT RD
Practice Address - Street 2:
Practice Address - City:ENID
Practice Address - State:OK
Practice Address - Zip Code:73705-5103
Practice Address - Country:US
Practice Address - Phone:580-213-7455
Practice Address - Fax:580-213-2169
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-07
Last Update Date:2016-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332000000XSuppliersMilitary/U.S. Coast Guard Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2146676OtherPK