Provider Demographics
NPI:1306915426
Name:121ST CSH/BAACH
Entity type:Organization
Organization Name:121ST CSH/BAACH
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER PHARMACY OPERATIONS CENTER
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:210-221-8274
Mailing Address - Street 1:2450 STANLEY RD STE 208
Mailing Address - Street 2:
Mailing Address - City:FORT SAM HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:78234-6108
Mailing Address - Country:US
Mailing Address - Phone:210-221-8274
Mailing Address - Fax:
Practice Address - Street 1:BLDG 795
Practice Address - Street 2:
Practice Address - City:CAMP HIALEAH
Practice Address - State:KOREA
Practice Address - Zip Code:AP
Practice Address - Country:KR
Practice Address - Phone:210-221-8274
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:121ST CSH/BAACH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-11-06
Last Update Date:2013-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332000000XSuppliersMilitary/U.S. Coast Guard Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
8210104OtherNCPDP