Healthcare Provider Details

I. General information

NPI: 1417799503
Provider Name (Legal Business Name): AMC EISENHOWER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/10/2024
Last Update Date: 06/11/2025
Certification Date: 06/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BULDG 1442 16TH STREET BLDG 1442
CAMP SHELBY MS
39407
US

IV. Provider business mailing address

BULDG 1442 16TH STREET BLDG 1442
CAMP SHELBY MS
39407
US

V. Phone/Fax

Practice location:
  • Phone: 601-558-4469
  • Fax:
Mailing address:
  • Phone: 601-558-4469
  • 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: DHA POD
Credential:
Phone: 210-536-6118