Provider Demographics
NPI:1356755185
Name:49TH MEDICAL GROUP
Entity type:Organization
Organization Name:49TH MEDICAL GROUP
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 1:49TH MEDICAL GROUP BALDWIN HERMAN S II
Mailing Address - Street 2:280 1ST STREET
Mailing Address - City:HOLLOMAN AFB
Mailing Address - State:NM
Mailing Address - Zip Code:88330-8273
Mailing Address - Country:US
Mailing Address - Phone:575-572-0524
Mailing Address - Fax:575-572-5781
Practice Address - Street 1:280 1ST ST BLDG 15
Practice Address - Street 2:
Practice Address - City:HOLLOMAN AFB
Practice Address - State:NM
Practice Address - Zip Code:88330-8273
Practice Address - Country:US
Practice Address - Phone:575-572-0524
Practice Address - Fax:575-572-5781
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-19
Last Update Date:2015-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332000000XSuppliersMilitary/U.S. Coast Guard Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2146416OtherPK