=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548673163
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | 412TH MEDGRP-EDWARDS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/11/2014
-----------------------------------------------------
Last Update Date | 06/12/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 30 NIGHTINGALE RD BLDG 5525
-----------------------------------------------------
City | EDWARDS AFB
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93524-1730
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 661-277-2052
-----------------------------------------------------
Fax | 661-277-8284
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 95 TH MEDICAL GROUP SGSR 30 NIGHTINGALE RD. BLDG 5525
-----------------------------------------------------
City | EDWARDS AFB
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93524-0001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 661-277-2052
-----------------------------------------------------
Fax | 661-277-8284
-----------------------------------------------------
=====================================================
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 |
-----------------------------------------------------