=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043319213
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AHC MONCRIEF-JACKSON
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/22/2006
-----------------------------------------------------
Last Update Date | 06/30/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4575 8TH DIVISION RD BLDG 4575
-----------------------------------------------------
City | COLUMBIA
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29207
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-751-7358
-----------------------------------------------------
Fax | 803-751-2451
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | BLDG 4575 MARION AVE
-----------------------------------------------------
City | FT JACKSON
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29207
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-751-7358
-----------------------------------------------------
Fax | 803-751-2451
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF DHA PASS
-----------------------------------------------------
Name | HECTOR MORALES
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 210-536-6650
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332000000X
-----------------------------------------------------
Taxonomy Name | Military/U.S. Coast Guard Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------