Healthcare Provider Details

I. General information

NPI: 1417356072
Provider Name (Legal Business Name): 27TH SPECIAL OPS MEDGRP-CANNON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/20/2014
Last Update Date: 09/02/2025
Certification Date: 09/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

224 WEST D. L. INGRAM BLVD BLDG 1408
CANNON AFB NM
88103-5103
US

IV. Provider business mailing address

27TH MEDICAL GROUP SGSL 208 W. D.L. INGRAM BLVD. 1ST FLOOR
CANNON AFB NM
88103
US

V. Phone/Fax

Practice location:
  • Phone: 575-784-4912
  • Fax: 575-784-7494
Mailing address:
  • Phone: 575-784-4028
  • Fax: 575-784-7494

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