Healthcare Provider Details

I. General information

NPI: 1083012223
Provider Name (Legal Business Name): 96TH MEDGRP-EGLIN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2014
Last Update Date: 06/11/2025
Certification Date: 06/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4315 EL SALVADOR WAY BUILDING 4315
EGLIN AFB FL
32542-1711
US

IV. Provider business mailing address

307 BOATNER RD STE 114
EGLIN AFB FL
32542-1302
US

V. Phone/Fax

Practice location:
  • Phone: 850-885-7554
  • Fax: 850-885-9977
Mailing address:
  • Phone: 850-885-7554
  • Fax: 850-885-9977

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