Healthcare Provider Details

I. General information

NPI: 1861804551
Provider Name (Legal Business Name): 316TH MEDGRP-MALCOLM GROW
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/29/2014
Last Update Date: 03/12/2025
Certification Date: 03/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

238 BROOKLEY AVE SW 579TH MEDICAL GROUP
BOLLING AFB DC
20032-7704
US

IV. Provider business mailing address

1060 W PERIMETER RD
JB ANDREWS MD
20762-6602
US

V. Phone/Fax

Practice location:
  • Phone: 202-404-7742
  • Fax: 202-404-1216
Mailing address:
  • Phone: 202-404-7742
  • Fax: 202-404-1216

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: WILLIAM MICHAEL CONDON
Title or Position: DHA FINANCIAL MANAGER
Credential:
Phone: 240-401-3643