Healthcare Provider Details

I. General information

NPI: 1114332368
Provider Name (Legal Business Name): 628TH MEDGRP-CHARLESTON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/26/2014
Last Update Date: 05/30/2025
Certification Date: 05/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

204 W HILL BLVD BLDG 364
CHARLESTON AFB SC
29404-4704
US

IV. Provider business mailing address

628 MEDICAL GROUP C/O RMO OFFICE 204 W. HILL BLVD. BLDG 364
CHARLESTON AFB SC
29404-4704
US

V. Phone/Fax

Practice location:
  • Phone: 843-963-6805
  • Fax: 843-963-6727
Mailing address:
  • Phone: 843-963-6805
  • Fax: 843-963-6727

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