Provider Demographics
NPI:1265539019
Name:316TH MEDGRP-MALCOLM GROW
Entity type:Organization
Organization Name:316TH MEDGRP-MALCOLM GROW
Other - Org Name:<UNAVAIL>
Other - Org Type:
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 1:1050 W PERIMETER RD
Mailing Address - Street 2:
Mailing Address - City:JB ANDREWS
Mailing Address - State:MD
Mailing Address - Zip Code:20762-6601
Mailing Address - Country:US
Mailing Address - Phone:434-292-2645
Mailing Address - Fax:
Practice Address - Street 1:1 SAN DIEGO LOOP BLDG 3188
Practice Address - Street 2:
Practice Address - City:JB ANDREWS
Practice Address - State:MD
Practice Address - Zip Code:20762-5518
Practice Address - Country:US
Practice Address - Phone:434-292-2645
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:316TH MEDGRP-MALCOLM GROW
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-09-20
Last Update Date:2025-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332000000XSuppliersMilitary/U.S. Coast Guard Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2037299OtherPK