Provider Demographics
NPI:1861800567
Name:359 MEDICAL GROUP
Entity type:Organization
Organization Name:359 MEDICAL GROUP
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 1:359 MEDICAL GROUP C/O 359 MDSS RESOURCE MANAGEMENT OFFI
Mailing Address - Street 2:221 3RD ST. W
Mailing Address - City:RANDOLPH AFB
Mailing Address - State:TX
Mailing Address - Zip Code:78150
Mailing Address - Country:US
Mailing Address - Phone:210-652-4189
Mailing Address - Fax:210-652-3516
Practice Address - Street 1:221 3RD ST W BLDG 1040
Practice Address - Street 2:
Practice Address - City:RANDOLPH AFB
Practice Address - State:TX
Practice Address - Zip Code:78150-4800
Practice Address - Country:US
Practice Address - Phone:210-652-4189
Practice Address - Fax:210-652-3516
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-25
Last Update Date:2015-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332000000XSuppliersMilitary/U.S. Coast Guard Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2147027OtherPK