Provider Demographics
NPI:1548673163
Name:95TH MEDICAL GROUP SGSR
Entity type:Organization
Organization Name:95TH MEDICAL GROUP SGSR
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 1:95 TH MEDICAL GROUP SGSR
Mailing Address - Street 2:30 NIGHTINGALE RD. BLDG 5525
Mailing Address - City:EDWARDS AFB
Mailing Address - State:CA
Mailing Address - Zip Code:93524-0001
Mailing Address - Country:US
Mailing Address - Phone:661-277-2052
Mailing Address - Fax:661-277-8284
Practice Address - Street 1:30 NIGHTINGALE RD
Practice Address - Street 2:BLDG 5525
Practice Address - City:EDWARDS AFB
Practice Address - State:CA
Practice Address - Zip Code:93524-1730
Practice Address - Country:US
Practice Address - Phone:661-277-2052
Practice Address - Fax:661-277-8284
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-11
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
2146265OtherPK