Healthcare Provider Details

I. General information

NPI: 1518379395
Provider Name (Legal Business Name): 316TH MEDGRP-MALCOLM GROW
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/28/2014
Last Update Date: 03/12/2025
Certification Date: 03/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1060 W PERIMETER RD
JOINT BASE ANDREWS MD
20762-6602
US

IV. Provider business mailing address

MALCOLM GROW MEDICAL CLINIC 779 MDG MDSS SGSR 1060 W. PERIMETER RD FB14 C/O RMO OFFICE
ANDREWS AFB MD
20762-6600
US

V. Phone/Fax

Practice location:
  • Phone: 240-612-2139
  • Fax: 240-612-3981
Mailing address:
  • Phone: 240-857-4566
  • 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: CHIEF DHA PASS
Credential:
Phone: 210-536-6650