Healthcare Provider Details

I. General information

NPI: 1568569317
Provider Name (Legal Business Name): HURLBURT MAIN PHCY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 03/26/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

113 LIELMANIS AVE BLDG 91020
HURLBURT FIELD FL
32544-5613
US

IV. Provider business mailing address

113 LIELMANIS AVE BLDG 91020
HURLBURT FIELD FL
32544-5613
US

V. Phone/Fax

Practice location:
  • Phone: 850-881-2133
  • Fax: 850-881-2323
Mailing address:
  • Phone:
  • Fax:

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: MGR PHRMCY OPERATIONS CNTR
Credential:
Phone: 210-221-8443