Provider Demographics
NPI:1740694553
Name:377TH MEDICAL GROUP - KIRTLAND AFB
Entity type:Organization
Organization Name:377TH MEDICAL GROUP - KIRTLAND AFB
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 1:377 TH MEDICAL GROUP
Mailing Address - Street 2:2050A SECOND ST. SE
Mailing Address - City:KIRTLAND AFB
Mailing Address - State:NM
Mailing Address - Zip Code:87117-0001
Mailing Address - Country:US
Mailing Address - Phone:505-846-7775
Mailing Address - Fax:505-846-3137
Practice Address - Street 1:1501 SAN PEDRO DR SE BLDG 47
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87108-5153
Practice Address - Country:US
Practice Address - Phone:505-846-7775
Practice Address - Fax:505-846-3137
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-19
Last Update Date:2024-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332000000XSuppliersMilitary/U.S. Coast Guard Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2146419OtherPK