628 MEDICAL GROUP (NPI# 1972602134) is a health care provider registered in Centers for Medicare & Medicaid Services (CMS), National Plan and Provider Enumeration System (NPPES).
| Nation Provider ID (NPI) | 1972602134 |
| Entity Type | Organization |
| Organization Name | 628 MEDICAL GROUP |
| Other Organization Name | CHARLESTON AFB MAIN PHCY |
| Practice Address |
204 W Hill Blvd Charleston Afb SC 29404-4704 |
| Mailing Address |
C/o Rmo Office 204 West Hill Blvd Bldg 364 Charleston Afb SC 29404-4704 |
| Practice Telephone | 8439636808 |
| Practice Fax Number | 8439636534 |
| Mailing Telephone | 8439636808 |
| Mailing Fax Number | 8439636534 |
| Enumeration Date | 2006-09-22 |
| Last Update Date | 2015-06-10 |
| Authorized Official Name | HECTOR MORALES (CHIEF DHA PASS) |
| Authorized Official Telephone | 2105366650 |
| Is Organization Subpart | N |
| Primary | Taxonomy Code | Classification | License Number | License State | Taxonomy Group |
|---|---|---|---|---|---|
| Y | 332000000X | Military/U.S. Coast Guard Pharmacy | Suppliers |
| State | Issuer | Identifier | Type Code |
|---|---|---|---|
| PK | 2091626 | 01 |
| Other Name | Type Code |
|---|---|
| CHARLESTON AFB MAIN PHCY | Doing Business As Name - Organization |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1114332368 | 628 Medical Group | Military/U.S. Coast Guard Pharmacy | 204 W Hill Blvd Bldg 364, Charleston Afb, SC 29404-4704 | 2014-06-26 |
| 1114905775 | 628 Medical Group | Military/U.S. Coast Guard Pharmacy | 204 W Hill Blvd, Bldg 364, Charleston Afb, SC 29404-4704 | 2006-01-04 |
| Street Address |
204 W HILL BLVD |
| City | CHARLESTON AFB |
| State | SC |
| Zip Code | 29404-4704 |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1831186360 | Darrell Kevin Tegtmeyer | Physician Assistant | 204 W Hill Blvd, Charleston Afb, SC 29404-4704 | 2005-09-30 |
| 1164080768 | Eric Wayne Robertson | Registered Nurse | 204 W Hill Blvd, Charleston Afb, SC 29404-4704 | 2019-05-30 |
| 1467938290 | Nicholas Trudo | Physician Assistant | 204 W Hill Blvd, Charleston Afb, SC 29404-4704 | 2018-07-16 |
| 1235655754 | Jessica Reynolds | Pharmacist | 204 W Hill Blvd, Charleston Afb, SC 29404-4704 | 2017-08-16 |
| 1356871032 | Karina Cortes | Military Health Care Provider | 204 W Hill Blvd, Charleston Afb, SC 29404-4704 | 2017-06-15 |
| 1093250839 | Thi Nguyen | Pharmacist | 204 W Hill Blvd, 628th Medical Group, Charleston Afb, SC 29404-4704 | 2017-01-03 |
| 1952857393 | Krystal Hasselvander | Social Worker | 204 W Hill Blvd, Charleston Afb, SC 29404-4704 | 2016-08-26 |
| 1447650502 | Jeffrey Chase Yee | Dentist | 204 W Hill Blvd, Charleston Afb, SC 29404-4704 | 2014-08-26 |
| 1659770980 | Khiem Nguyen | Dentist | 204 W Hill Blvd, Charleston Afb, SC 29404-4704 | 2014-08-22 |
| 1063852978 | Chantell Renee Mckee | Family Medicine | 204 W Hill Blvd, Charleston Afb, SC 29404 | 2013-06-25 |
| Find all providers in the same location | ||||
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1346751971 | James Tyrone Wilder | Social Worker | B, 1001 Michigan Ave, Joint Base, Charleston, SC 29404 | 2017-10-23 |
| 1033422902 | Michael Ryan Moore | Physical Therapist | 628th Medical Group, 204 West Hill Blvd, Charleston, SC 29404 | 2010-07-21 |
| 1720221013 | Cristy Jo Preslar | Military Health Care Provider | 364 Arthur Drive, Charleston Afb, SC 29404 | 2009-04-16 |
| 1336237627 | Douglas Vail Campbell | Psychologist | 437mdos/lssc - 204 West Hill Blvd, Charleston Afb, SC 29404 | 2006-10-11 |
| 1124019914 | Neal Robert Taylor | Family Medicine | 628 Medical Group 204 W. Hill Blvd, Jb Charleston, SC 29404 | 2005-11-02 |
| 1295092328 | Suzanne M O'shea | Registered Nurse | 204 W. Hill Blvd, Charleston, SC 29404-0000 | 2012-04-13 |
| 1306281373 | Michelle Karen Calandra | Registered Nurse | 1000 Michigan Ave, Charleston Afb, SC 29404-2020 | 2013-05-06 |
| 1336560440 | Merin Williams | Speech-Language Pathologist | 1000 Michigan Ave, Charleston Afb, SC 29404-2020 | 2013-12-17 |
| 1154884468 | Palmetto Pa Assist, LLC | Physician Assistant | 101 Lawson Dr # 103, Charleston, SC 29404-2121 | 2019-04-12 |
| 1750811089 | Radiant Neuromonitoring LLC | Psychiatry & Neurology | 101 Lawson Dr # 104, Charleston, SC 29404-2121 | 2017-06-19 |
| Find all providers in zip 29404 | ||||
| Taxonomy Code | 332000000X |
| Grouping | Suppliers |
| Classification | Military/U.S. Coast Guard Pharmacy |
| A Department of Defense (DoD) or U.S. Coast Guard entity whose primary function is to store, prepare and dispense pharmaceuticals and other associated items to Uniformed Services beneficiaries. These pharmacies may be associated with a DoD or U.S. Coast Guard clinic, DoD Hospital or freestanding. Usually associated with outpatient services. |
| Notes: Source: TRICARE Management Activity Uniform Business Office User’s Guide [1/1/2005: new; 7/1/2006: modified title, modified definition] |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1114332368 | 628 Medical Group | Military/U.S. Coast Guard Pharmacy | 204 W Hill Blvd Bldg 364, Charleston Afb, SC 29404-4704 | 2014-06-26 |
| 1114905775 | 628 Medical Group | Military/U.S. Coast Guard Pharmacy | 204 W Hill Blvd, Bldg 364, Charleston Afb, SC 29404-4704 | 2006-01-04 |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1669877064 | Moncrief Army Community Hospital | Military/U.S. Coast Guard Pharmacy | 1021 Pinnacle Point Dr Ste 200, Columbia, SC 29223-5740 | 2014-10-28 |
| 1306945563 | Naval Hospital Beaufort | Military/U.S. Coast Guard Pharmacy | Bldg 669, Parris Island, SC 29905 | 2006-09-22 |
| 1235238411 | Moncrief Army Community Hospital | Military/U.S. Coast Guard Pharmacy | Bldg 4500, Stuart Street, Ft Jackson, SC 29207 | 2006-09-22 |
| 1043319213 | Moncrief Army Community Hospital | Military/U.S. Coast Guard Pharmacy | Bldg 4575, Marion Ave, Ft Jackson, SC 29207 | 2006-09-22 |
| 1881793057 | Moncrief Army Community Hospital | Military/U.S. Coast Guard Pharmacy | Bldg 4716, Commissary Rd, Ft Jackson, SC 29207 | 2006-09-22 |
| 1760581946 | 20th Medical Group Sgsl | Military/U.S. Coast Guard Pharmacy | 515 Exchange St, Bldg 1448, Shaw Afb, SC 29152-5033 | 2006-09-22 |
| 1881009033 | 20th Medical Support Squadron | Military/U.S. Coast Guard Pharmacy | 431 Meadowlark St, Shaw Afb, SC 29152-5019 | 2014-06-26 |
| 1811309339 | Naval Hospital Beaufort | Military/U.S. Coast Guard Pharmacy | 1 Pinckney Blvd, Naval Hospital Beaufort, Beaufort, SC 29902 | 2014-06-02 |
| 1073802807 | Moncrief Army Community Hospital | Military/U.S. Coast Guard Pharmacy | 4500 Stuart Ave, Columbia, SC 29207-5700 | 2011-04-01 |
| 1881793040 | Naval Hospital Beaufort | Military/U.S. Coast Guard Pharmacy | 1 Pinckney Blvd, Bldg 1, Beaufort, SC 29902 | 2006-09-22 |
| Find all providers with the same taxonomy | ||||
| City | CHARLESTON AFB |
| Zip Code | 29404 |
Please comment or provide details below to improve the information on 628 MEDICAL GROUP.
| Data Provider | Centers for Medicare & Medicaid Services (CMS), National Plan and Provider Enumeration System (NPPES) |
| Jurisdiction | Medicare & Medicaid |
This dataset includes 5.44 million covered health care providers and all health plans and health care clearinghouses, registered with CMA NPPES. Each provider is registered with National Provider Identifier (NPI), full name, status, address, taxonomy, other identifiers, etc.