MEDICARE: HOUSTON USCG ELLINGTON FLD PHCY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332000000X	Military/U.S. Coast Guard Pharmacy

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	4526010	OTHER		OTHER ID NUMBER-COMMERCIAL NUMBER

General Provider Information

NPI Number	:	1316044167
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HOUSTON USCG ELLINGTON FLD PHCY

Provider Business Mailing Address
First Line	:	1178 ELLINGTON FLD
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77034-5513
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1178 ELLINGTON FLD
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77034-5513
Country	:	US
Telephone Number	:	281-929-2421
Fax Number	:

Authorized Official
Title or Position	:	MGR PHRMCY OPERATIONS CNTR
Name	:	HECTOR MORALES
Credential	:
Telephone Number	:	210-221-8443

Provider Enumeration Date	:	09/20/2006
Last Update Date	:	04/15/2009

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