Provider Demographics
NPI:1902218415
Name:354 MDG
Entity Type:Organization
Organization Name:354 MDG
Other - Org Name:DOD EIELSON PHARMACY
Other - Org Type:Doing Business As
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 1:354 MDG
Mailing Address - Street 2:2630 CENTAL AVE STE 1M07
Mailing Address - City:EIELSON AFB
Mailing Address - State:AK
Mailing Address - Zip Code:99702-2325
Mailing Address - Country:US
Mailing Address - Phone:907-377-1462
Mailing Address - Fax:907-377-4105
Practice Address - Street 1:2630 CENTRAL AVE STE 1M07
Practice Address - Street 2:
Practice Address - City:EIELSON AFB
Practice Address - State:AK
Practice Address - Zip Code:99702-2325
Practice Address - Country:US
Practice Address - Phone:907-377-1462
Practice Address - Fax:907-377-4105
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-02
Last Update Date:2021-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332000000XSuppliersMilitary/U.S. Coast Guard Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2146023OtherPK