Healthcare Provider Details

I. General information

NPI: 1487053435
Provider Name (Legal Business Name): 42D MEDGRP-MAXWELL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/15/2014
Last Update Date: 07/25/2025
Certification Date: 07/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 TWINING ST
MAXWELL AFB AL
36112-6027
US

IV. Provider business mailing address

USAF-MAXWELL HOSPITAL/SGL 300 SOUTH TWINING ST. BLDG. 760
MAXWELL AFB AL
36112-0000
US

V. Phone/Fax

Practice location:
  • Phone: 334-953-9333
  • Fax: 334-953-5272
Mailing address:
  • Phone: 334-953-9333
  • Fax: 334-953-5272

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code332000000X
TaxonomyMilitary/U.S. Coast Guard Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: HECTOR MORALES
Title or Position: DHA POD
Credential:
Phone: 210-536-6118