628TH Medgrp-Charleston

Primary specialty

Military/U.S. Coast Guard Outpatient Clinic/CenterTaxonomy code 261QM1100X

Legal business name

628TH MEDGRP-CHARLESTON

Practice address

204 W Hill Blvd
BLDG 364
Charleston AFB, SC 29404-4704

Phone

(843) 963-6884

Fax

(843) 963-6538

NPI assigned

Jan 4, 2006

Last updated

Jun 17, 2025By the provider in NPPES

Organization subpart

Yes

Parent organization

628TH MEDGRP-CHARLESTONAs reported in NPPES

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Jen Lewandowski

Title

Dha Ubo

Phone

(703) 817-4030

Specialties & licenses 3

Addresses

Other identifiers 1

Tax ID family

628TH Medgrp-Charleston2 organizations share this tax ID, including this one

Part of

628TH Medgrp-Charleston

Other organizations with this tax ID 1

Organizations that report the same tax identification number in the National Provider Directory.

• 628TH Medgrp-Charleston

  dba Dod Charleston AFB Pharmacy

  • Military/U.S. Coast Guard Pharmacy
  • Charleston AFB, SC
  • NPI 1114332368
  NPD tax ID

Locations

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1136332800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1750118400000",
    "number": "1114905775",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "204 W HILL BLVD",
            "address_2": "BLDG 364",
            "city": "CHARLESTON AFB",
            "state": "SC",
            "postal_code": "294044704",
            "telephone_number": "843-963-6884",
            "fax_number": "843-963-6538"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "204 W HILL BLVD",
            "address_2": "BLDG 364",
            "city": "CHARLESTON AFB",
            "state": "SC",
            "postal_code": "294044704",
            "telephone_number": "843-963-6884",
            "fax_number": "843-963-6538"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "628TH MEDGRP-CHARLESTON",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "628TH MEDGRP-CHARLESTON",
        "enumeration_date": "2006-01-04",
        "last_updated": "2025-06-17",
        "certification_date": "2025-06-17",
        "status": "A",
        "authorized_official_last_name": "LEWANDOWSKI",
        "authorized_official_first_name": "JEN",
        "authorized_official_title_or_position": "DHA UBO",
        "authorized_official_telephone_number": "703-817-4030"
    },
    "taxonomies": [
        {
            "code": "261QM1100X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Military/U.S. Coast Guard Outpatient",
            "state": "NU",
            "license": null,
            "primary": true
        },
        {
            "code": "261QM1101X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Military and U.S. Coast Guard Ambulatory Procedure",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "332000000X",
            "taxonomy_group": "",
            "desc": "Military/U.S. Coast Guard Pharmacy",
            "state": "NU",
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "NCPDP",
            "identifier": "42-22181",
            "state": "SC"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• 628TH Medgrp-Charleston (Dod Charleston AFB Pharmacy)
• George James Antolick, IDMT
• Karen Berkeley, PHARMD
• Shannon L Bolen, MSW
• James Edwin Boyd, M.D.
• Robert Ray Bryant, PA

• Military/U.S. Coast Guard Outpatient Clinic/Center in Charleston AFB, SC
• Providers in Charleston AFB, SC by specialty
• Military/U.S. Coast Guard Outpatient Clinic/Center in South Carolina

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 17, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.