Provider Demographics
NPI:1942616057
Name:99TH MEDGRP-NELLIS
Entity type:Organization
Organization Name:99TH MEDGRP-NELLIS
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:MIKE OCALLAGHAN FEDERAL HOSPITAL C/O FRANCES BANTUGAN
Mailing Address - Street 2:4700 LAS VEGAS BLVD N.
Mailing Address - City:NELLIS AFB
Mailing Address - State:NV
Mailing Address - Zip Code:89191
Mailing Address - Country:US
Mailing Address - Phone:702-653-2747
Mailing Address - Fax:702-653-2755
Practice Address - Street 1:4700 LAS VEGAS BLVD N
Practice Address - Street 2:
Practice Address - City:NELLIS AFB
Practice Address - State:NV
Practice Address - Zip Code:89191-6600
Practice Address - Country:US
Practice Address - Phone:702-653-2747
Practice Address - Fax:702-653-2755
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:99TH MEDGRP-NELLIS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-07-09
Last Update Date:2025-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332000000XSuppliersMilitary/U.S. Coast Guard Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2146757OtherPK