Healthcare Provider Details

I. General information

NPI: 1699269852
Provider Name (Legal Business Name): 59TH MDW-WHASC-LACKLAND
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/20/2018
Last Update Date: 06/13/2025
Certification Date: 06/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1940 CARSWELL AVE BLDG 7002
LACKLAND TX
78236
US

IV. Provider business mailing address

1940 CARSWELL AVE BLDG 7002
LACKLAND TX
78236
US

V. Phone/Fax

Practice location:
  • Phone: 210-671-9637
  • Fax: 210-671-6486
Mailing address:
  • Phone: 210-671-9637
  • Fax: 210-671-6486

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: CYNTHIA DE LA CRUZ
Title or Position: MTF SUPPORT
Credential:
Phone: 210-536-6650