Healthcare Provider Details

I. General information

NPI: 1508522939
Provider Name (Legal Business Name): USCG TRAVERSE CITY PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/10/2021
Last Update Date: 11/10/2021
Certification Date: 10/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1175 AIRPORT RD
TRAVERSE CITY MI
49686
US

IV. Provider business mailing address

300 E MAIN ST STE 1000
NORFOLK VA
23510-9109
US

V. Phone/Fax

Practice location:
  • Phone: 231-922-8290
  • Fax: 231-922-8292
Mailing address:
  • Phone: 231-922-8290
  • Fax: 231-922-8292

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