MEDICARE: 359TH MDG

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	2093375	OTHER		PK

General Provider Information

NPI Number	:	1598862344
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	359TH MDG

Provider Business Mailing Address
First Line	:	221 3RD ST W BLDG 1040
Second Line	:
City	:	UNIVERSAL CITY
State	:	TX
Zip	:	78150-4800
Country	:	US
Telephone Number	:	210-652-4127
Fax Number	:	210-652-3516

Provider Business Practice Location Address
First Line	:	221 3RD ST W BLDG 1040
Second Line	:
City	:	UNIVERSAL CITY
State	:	TX
Zip	:	78150-4800
Country	:	US
Telephone Number	:	210-652-4127
Fax Number	:	210-652-3516

Authorized Official
Title or Position	:	CHIEF DHA PASS
Name	:	HECTOR MORALES
Credential	:
Telephone Number	:	210-536-6650

Provider Enumeration Date	:	09/20/2006
Last Update Date	:	01/13/2016

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Directions to “359TH MDG ” Practice Location

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