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General NPI Number Information
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NPI Number | 1144636515
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Entity Type | Organization
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Legal Business Name | 366TH MEDGRP-MOUNTAIN HOME
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Dates
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Enumeration Date | 07/07/2014
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Last Update Date | 06/13/2025
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Provider Practice Location Address
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Address Line | 90 HOPE DR BLDG 6000
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City | MOUNTAIN HOME AFB
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State | ID
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Zip | 83648-1062
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Country | US
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Telephone | 208-828-7521
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Fax | 208-828-7676
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Provider Business Mailing Address
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Address Line | 366 MEDICAL GROUP SGSBF 90 HOPE DR. BLDG. 6000
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City | MTN HOME AFB
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State | ID
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Zip | 83648-1062
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Country | US
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Telephone | 208-828-7521
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Fax | 208-828-7676
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Authorized Official
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Title or Position | CHIEF DHA PASS
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Name | HECTOR MORALES
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Credential |
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Telephone | 210-536-6650
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 333600000X
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Taxonomy Name | Pharmacy
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 332000000X
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Taxonomy Name | Military/U.S. Coast Guard Pharmacy
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License Number |
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License Number State |
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