Healthcare Provider Details

I. General information

NPI: 1043622681
Provider Name (Legal Business Name): 60TH MEDGRP-TRAVIS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/02/2014
Last Update Date: 03/12/2025
Certification Date: 03/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

461 SKYMASTER CIR RM 149
TRAVIS AFB CA
94535-1909
US

IV. Provider business mailing address

DAVID S GRANT MEDICAL CENTER CO 60TH MDG 101 BODIN CIR
TRAVIS AFB CA
94535-1809
US

V. Phone/Fax

Practice location:
  • Phone: 707-423-5345
  • Fax: 707-423-5346
Mailing address:
  • Phone: 707-423-7657
  • Fax: 707-423-7994

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