Provider Demographics
NPI:1275632465
Name:96TH MEDICAL SUPPORT SQUADRON SGSL
Entity Type:Organization
Organization Name:96TH MEDICAL SUPPORT SQUADRON SGSL
Other - Org Name:ARNOLD PHCY
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 1:96TH MEDICAL SUPPORT SQUADRON
Mailing Address - Street 2:307 BOATNER RD STE 114
Mailing Address - City:ARNOLD AFB
Mailing Address - State:TN
Mailing Address - Zip Code:32542-1302
Mailing Address - Country:US
Mailing Address - Phone:931-454-5351
Mailing Address - Fax:931-454-3392
Practice Address - Street 1:225 FIRST ST BLDG 225
Practice Address - Street 2:
Practice Address - City:ARNOLD AFB
Practice Address - State:TN
Practice Address - Zip Code:37389
Practice Address - Country:US
Practice Address - Phone:931-454-5351
Practice Address - Fax:931-454-3392
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-22
Last Update Date:2015-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332000000XSuppliersMilitary/U.S. Coast Guard Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2092941OtherPK