Healthcare Provider Details

I. General information

NPI: 1225444334
Provider Name (Legal Business Name): 509TH MEDGRP-WHITEMAN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/09/2014
Last Update Date: 05/29/2025
Certification Date: 05/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

331 SIJEN AVE
WHITEMAN AFB MO
65305-1269
US

IV. Provider business mailing address

509TH MEDICAL GROUP-SGSR 331 SIJAN AVE.
WHITEMAN AFB MO
65305
US

V. Phone/Fax

Practice location:
  • Phone: 660-687-1774
  • Fax: 660-687-1878
Mailing address:
  • Phone: 660-687-1774
  • Fax: 660-687-1878

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