1114332368 NPI number — 628 MEDICAL GROUP

Table of content: (NPI 1114332368)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114332368 NPI number — 628 MEDICAL GROUP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
628 MEDICAL GROUP
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
DOD CHARLESTON AFB PHARMACY
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1114332368
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/07/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
628 MEDICAL GROUP C/O RMO OFFICE
Provider Second Line Business Mailing Address:
204 W. HILL BLVD. BLDG 364
Provider Business Mailing Address City Name:
CHARLESTON AFB
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29404-4704
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
843-963-6805
Provider Business Mailing Address Fax Number:
843-963-6727

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
204 W HILL BLVD BLDG 364
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHARLESTON AFB
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29404-4704
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-963-6805
Provider Business Practice Location Address Fax Number:
843-963-6727
Provider Enumeration Date:
06/26/2014

Additional Information

Authorized Official

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

Provider Taxonomy Codes

  • Taxonomy code: 332000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2146517 . This is a "PK" identifier . This identifiers is of the category "OTHER".




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