Healthcare Provider Details

I. General information

NPI: 1740694553
Provider Name (Legal Business Name): 377TH MEDGRP-KIRTLAND
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/19/2014
Last Update Date: 06/13/2025
Certification Date: 06/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 SAN PEDRO DR SE BLDG 47
ALBUQUERQUE NM
87108-5153
US

IV. Provider business mailing address

377 TH MEDICAL GROUP 2050A SECOND ST. SE
KIRTLAND AFB NM
87117-0001
US

V. Phone/Fax

Practice location:
  • Phone: 505-846-7775
  • Fax: 505-846-3137
Mailing address:
  • Phone: 505-846-7775
  • Fax: 505-846-3137

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