Healthcare Provider Details

I. General information

NPI: 1972602613
Provider Name (Legal Business Name): 96TH MEDICAL SUPPORT SQUADRON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/21/2006
Last Update Date: 06/11/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

307 BOATNER RD STE 114 BLDG 1405
EGLIN AFB FL
32542-1302
US

IV. Provider business mailing address

96TH MEDICAL SUPPORT SQUADRON 307 BOATNER RD STE
EGLIN AFB FL
32542-1302
US

V. Phone/Fax

Practice location:
  • Phone: 850-883-8444
  • Fax: 850-883-8429
Mailing address:
  • Phone: 850-883-8444
  • Fax: 850-883-8429

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