Healthcare Provider Details

I. General information

NPI: 1265756316
Provider Name (Legal Business Name): 86TH MDSS SGSAP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/18/2010
Last Update Date: 03/18/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BLDG 2114 86TH MDSS SGSAP UNIT 3215
APO AE
09094-3214
US

IV. Provider business mailing address

2450 STANLEY RD STE 208
FORT SAM HOUSTON TX
78234-6108
US

V. Phone/Fax

Practice location:
  • Phone: 314-479-2541
  • Fax:
Mailing address:
  • Phone: 210-221-8443
  • Fax: 210-295-2567

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332000000X
TaxonomyMilitary/U.S. Coast Guard Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: HECTOR MORALES
Title or Position: DEPUTY DIRECTOR PHARMACY OPS CTR
Credential:
Phone: 210-221-8443