Healthcare Provider Details

I. General information

NPI: 1487753521
Provider Name (Legal Business Name): 56TH MEDICAL GROUP SGSL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/22/2006
Last Update Date: 03/30/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7219 N LITCHFIELD RD BLDG 1130 RM C04
LUKE AFB AZ
85309-1529
US

IV. Provider business mailing address

7219 N LITCHFIELD RD BLDG 1130 RM C04
LUKE AFB AZ
85309-1529
US

V. Phone/Fax

Practice location:
  • Phone: 623-856-3068
  • Fax: 623-856-6120
Mailing address:
  • Phone: 623-856-3068
  • Fax: 623-856-6120

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