Healthcare Provider Details

I. General information

NPI: 1063829414
Provider Name (Legal Business Name): 59TH MDW-WHASC-LACKLAND
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/17/2014
Last Update Date: 06/13/2025
Certification Date: 06/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2275 REESE ST
LACKLAND AFB TX
78236-1245
US

IV. Provider business mailing address

WILFORD HALL MEDICAL CENTER C/O 59 MDW CASHIER CAGE 2200 BERQUIST DR. STE. 1
LACKLAND AFB TX
78236
US

V. Phone/Fax

Practice location:
  • Phone: 210-292-7970
  • Fax: 210-292-7207
Mailing address:
  • Phone: 210-292-7970
  • Fax: 210-292-7207

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