Provider Demographics
NPI:1740692433
Name:436 MEDICAL GRP
Entity type:Organization
Organization Name:436 MEDICAL GRP
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 1:436 MEDICAL GRP HEALTH CARE C/O DONALD COLE
Mailing Address - Street 2:300 TUSKEGEE BLVD
Mailing Address - City:DOVER
Mailing Address - State:DE
Mailing Address - Zip Code:19901
Mailing Address - Country:US
Mailing Address - Phone:302-677-2019
Mailing Address - Fax:302-677-4030
Practice Address - Street 1:300 TUSKEGEE BLVD
Practice Address - Street 2:
Practice Address - City:DOVER AFB
Practice Address - State:DE
Practice Address - Zip Code:19902-5003
Practice Address - Country:US
Practice Address - Phone:302-677-2019
Practice Address - Fax:302-677-4030
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-29
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332000000XSuppliersMilitary/U.S. Coast Guard Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2145986OtherPK