Healthcare Provider Details

I. General information

NPI: 1861800567
Provider Name (Legal Business Name): 59TH MDW-WHASC-LACKLAND
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/25/2014
Last Update Date: 07/28/2025
Certification Date: 07/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

221 3RD ST W BLDG 1040
RANDOLPH AFB TX
78150-4800
US

IV. Provider business mailing address

359 MEDICAL GROUP C/O 359 MDSS RESOURCE MANAGEMENT OFFI 221 3RD ST. W
RANDOLPH AFB TX
78150
US

V. Phone/Fax

Practice location:
  • Phone: 210-652-4189
  • Fax: 210-652-3516
Mailing address:
  • Phone: 210-652-4189
  • Fax: 210-652-3516

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: DHA POD
Credential:
Phone: 210-536-6118