Healthcare Provider Details

I. General information

NPI: 1598177370
Provider Name (Legal Business Name): 97TH MEDGRP-ALTUS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/28/2014
Last Update Date: 07/28/2025
Certification Date: 07/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 N 1ST ST BLDG 46
ALTUS AFB OK
73523-5004
US

IV. Provider business mailing address

97 MDG MSC FUND C/O MSC TREASURER TSG MARIA DELEON 301 N FIRST ST. BLDG 46
ALTUS AFB OK
73523
US

V. Phone/Fax

Practice location:
  • Phone: 580-481-5258
  • Fax: 580-481-7420
Mailing address:
  • Phone: 580-481-5258
  • 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
# 2
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State

VIII. Authorized Official

Name: HECTOR MORALES
Title or Position: DHA POD
Credential:
Phone: 210-536-6118