Organization
628TH MEDGRP-CHARLESTON
Active
Parent organization
628TH MEDGRP-CHARLESTON
Organization subpart
Yes
Provider details
NPI number
Legal business name
628TH MEDGRP-CHARLESTON
Authorized official
JEN LEWANDOWSKI (DHA UBO)
(703) 817-4030
Entity
Organization
Contact information
Practice address
204 W HILL BLVD, BLDG 364, CHARLESTON AFB, SC 29404-4704
(843) 963-6884
(843) 963-6538
Mailing address
204 W HILL BLVD, BLDG 364, CHARLESTON AFB, SC 29404-4704
(843) 963-6884
(843) 963-6538
Taxonomy
Speciality
Code
Description
License number
State
261QM1100X
Military/U.S. Coast Guard Outpatient Clinic/Center
Primary
—
—
261QM1101X
Military and U.S. Coast Guard Ambulatory Procedure Clinic/Center
—
—
332000000X
Military/U.S. Coast Guard Pharmacy
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
42-22181
NCPDP
SC
Enumeration date
01/04/2006
Last updated
06/17/2025
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