=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619381449
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | 75TH MEDGRP-HILL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/19/2014
-----------------------------------------------------
Last Update Date | 06/13/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5845 E AVE BLDG 412
-----------------------------------------------------
City | HILL AFB
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84056-5303
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-586-9530
-----------------------------------------------------
Fax | 801-586-9890
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 75TH MEDICAL GROUP SGSB 7321 11TH ST BLDG 570
-----------------------------------------------------
City | HILL AFB
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84056-5012
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-586-9530
-----------------------------------------------------
Fax | 801-586-9890
-----------------------------------------------------
=====================================================
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 |
-----------------------------------------------------