Healthcare Provider Details

I. General information

NPI: 1902218415
Provider Name (Legal Business Name): 354TH MEDGRP-EIELSON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/02/2014
Last Update Date: 06/12/2025
Certification Date: 06/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2630 CENTRAL AVE STE 1M07
EIELSON AFB AK
99702-2325
US

IV. Provider business mailing address

354 MDG 2630 CENTAL AVE STE 1M07
EIELSON AFB AK
99702-2325
US

V. Phone/Fax

Practice location:
  • Phone: 907-377-1462
  • Fax: 907-377-4105
Mailing address:
  • Phone: 907-377-1462
  • Fax: 907-377-4105

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: CHIEF DHA PASS
Credential:
Phone: 210-536-6650