Provider Demographics
NPI:1760581946
Name:20TH MEDICAL GROUP SGSL
Entity type:Organization
Organization Name:20TH MEDICAL GROUP SGSL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF DHA PASS
Authorized Official - Prefix:
Authorized Official - First Name:HECTOR
Authorized Official - Middle Name:
Authorized Official - Last Name:MORALES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:210-536-6650
Mailing Address - Street 1:515 EXCHANGE ST
Mailing Address - Street 2:BLDG 1448
Mailing Address - City:SHAW AFB
Mailing Address - State:SC
Mailing Address - Zip Code:29152-5033
Mailing Address - Country:US
Mailing Address - Phone:864-895-1309
Mailing Address - Fax:864-895-6463
Practice Address - Street 1:515 EXCHANGE ST
Practice Address - Street 2:BLDG 1448
Practice Address - City:SHAW AFB
Practice Address - State:SC
Practice Address - Zip Code:29152-5033
Practice Address - Country:US
Practice Address - Phone:864-895-1309
Practice Address - Fax:864-895-6463
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-22
Last Update Date:2016-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332000000XSuppliersMilitary/U.S. Coast Guard Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2091776OtherPK