Healthcare Provider Details

I. General information

NPI: 1184122749
Provider Name (Legal Business Name): 59TH MDW-WHASC-LACKLAND
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/30/2018
Last Update Date: 06/13/2025
Certification Date: 06/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25615 NORTH 281 SUITE 215
SAN ANTONIO TX
78258
US

IV. Provider business mailing address

25615 NORTH 281 SUITE 215
SAN ANTONIO TX
78258
US

V. Phone/Fax

Practice location:
  • Phone: 210-292-7970
  • Fax: 210-292-8000
Mailing address:
  • Phone: 210-292-0121
  • Fax: 210-292-8000

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
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 OF THE PASS
Credential:
Phone: 210-536-6650