Provider Demographics
NPI:1104925585
Name:60TH MEDICAL GROUP
Entity type:Organization
Organization Name:60TH MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:MARCOS
Authorized Official - Middle Name:
Authorized Official - Last Name:LOPEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-423-3459
Mailing Address - Street 1:2569 SHOREY WAY
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94533-6562
Mailing Address - Country:US
Mailing Address - Phone:707-423-6459
Mailing Address - Fax:
Practice Address - Street 1:101 BODIN CIR
Practice Address - Street 2:
Practice Address - City:TRAVIS AFB
Practice Address - State:CA
Practice Address - Zip Code:94535-1809
Practice Address - Country:US
Practice Address - Phone:707-423-3459
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2008-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR4679286500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes286500000XHospitalsMilitary Hospital