Healthcare Provider Details

I. General information

NPI: 1104011667
Provider Name (Legal Business Name): ATLANTIC CITY USCG PHCY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/07/2007
Last Update Date: 09/07/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

AMELIA EARHART ROAD BLDG 350
ATLANTIC CITY NJ
08405-0001
US

IV. Provider business mailing address

2450 STANLEY RD SUITE 208
FORT SAM HOUSTON TX
78234-7510
US

V. Phone/Fax

Practice location:
  • Phone: 609-677-2028
  • Fax:
Mailing address:
  • Phone: 210-221-8443
  • 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: MR. HECTOR MORALES
Title or Position: MANAGER DOD PHARMACY OPS
Credential:
Phone: 210-221-8443