Provider Demographics
NPI:1356405336
Name:75 MDG PHARMACY
Entity type:Organization
Organization Name:75 MDG PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACY FLIGHT COMMANDER
Authorized Official - Prefix:MR
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:COSENTINO
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:801-586-9529
Mailing Address - Street 1:7321 11TH ST BLDG 570
Mailing Address - Street 2:
Mailing Address - City:HILL AFB
Mailing Address - State:UT
Mailing Address - Zip Code:84056-5012
Mailing Address - Country:US
Mailing Address - Phone:801-777-0419
Mailing Address - Fax:801-586-9890
Practice Address - Street 1:7321 11TH ST BLDG 570
Practice Address - Street 2:
Practice Address - City:HILL AFB
Practice Address - State:UT
Practice Address - Zip Code:84056-5012
Practice Address - Country:US
Practice Address - Phone:801-777-0419
Practice Address - Fax:801-586-9890
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-21
Last Update Date:2008-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
4609268OtherNCPDP