Provider Demographics
NPI:1518379395
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:MALCOLM GROW MEDICAL CLINIC 779 MDG MDSS SGSR
Mailing Address - Street 2:1060 W. PERIMETER RD FB14 C/O RMO OFFICE
Mailing Address - City:ANDREWS AFB
Mailing Address - State:MD
Mailing Address - Zip Code:20762-6600
Mailing Address - Country:US
Mailing Address - Phone:240-857-4566
Mailing Address - Fax:
Practice Address - Street 1:1060 W PERIMETER RD
Practice Address - Street 2:
Practice Address - City:JOINT BASE ANDREWS
Practice Address - State:MD
Practice Address - Zip Code:20762-6602
Practice Address - Country:US
Practice Address - Phone:240-612-2139
Practice Address - Fax:240-612-3981
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:316TH MEDGRP-MALCOLM GROW
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-05-28
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
2145938OtherPK