Provider Demographics
NPI:1386743524
Name:KELLY OP PHCY
Entity type:Organization
Organization Name:KELLY OP PHCY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MGR PHRMCY OPERATIONS CNTR
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:210-221-8443
Mailing Address - Street 1:204 WAGNER DR
Mailing Address - Street 2:BLDG 1740
Mailing Address - City:KELLY AFB
Mailing Address - State:TX
Mailing Address - Zip Code:78241-5846
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:204 WAGNER DR
Practice Address - Street 2:BLDG 1740
Practice Address - City:KELLY AFB
Practice Address - State:TX
Practice Address - Zip Code:78241-5846
Practice Address - Country:US
Practice Address - Phone:210-925-8304
Practice Address - Fax:210-292-1962
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-22
Last Update Date:2009-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332000000XSuppliersMilitary/U.S. Coast Guard Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
4511944OtherOTHER ID NUMBER-COMMERCIAL NUMBER