Healthcare Provider Details

I. General information

NPI: 1144636515
Provider Name (Legal Business Name): 366TH MEDGRP-MOUNTAIN HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2014
Last Update Date: 06/13/2025
Certification Date: 06/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

90 HOPE DR BLDG 6000
MOUNTAIN HOME AFB ID
83648-1062
US

IV. Provider business mailing address

366 MEDICAL GROUP SGSBF 90 HOPE DR. BLDG. 6000
MTN HOME AFB ID
83648-1062
US

V. Phone/Fax

Practice location:
  • Phone: 208-828-7521
  • Fax: 208-828-7676
Mailing address:
  • Phone: 208-828-7521
  • Fax: 208-828-7676

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
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