Healthcare Provider Details

I. General information

NPI: 1063511707
Provider Name (Legal Business Name): 45TH MEDICAL GROUP SGSL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/21/2006
Last Update Date: 08/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1381 S PATRICK DR
PATRICK AFB FL
32925-3606
US

IV. Provider business mailing address

1381 S PATRICK DR
PATRICK AFB FL
32925-3606
US

V. Phone/Fax

Practice location:
  • Phone: 321-494-8991
  • Fax: 321-494-7996
Mailing address:
  • Phone: 321-494-8991
  • Fax: 321-494-7996

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