Provider Demographics
NPI:1801959473
Name:MT HOME REFILL PHCY
Entity type:Organization
Organization Name:MT HOME REFILL PHCY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACY OPERATIONS CENTER MGR
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:210-221-8443
Mailing Address - Street 1:90 HOPE DR
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME AFB
Mailing Address - State:ID
Mailing Address - Zip Code:83648
Mailing Address - Country:US
Mailing Address - Phone:208-828-7480
Mailing Address - Fax:208-828-3785
Practice Address - Street 1:90 HOPE DR
Practice Address - Street 2:
Practice Address - City:MOUNTAIN HOME AFB
Practice Address - State:ID
Practice Address - Zip Code:83648
Practice Address - Country:US
Practice Address - Phone:208-828-7480
Practice Address - Fax:208-828-3785
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-18
Last Update Date:2008-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332000000XSuppliersMilitary/U.S. Coast Guard Pharmacy