Healthcare Provider Details

I. General information

NPI: 1912983065
Provider Name (Legal Business Name): ISLA HOME INFUSION INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/21/2005
Last Update Date: 10/20/2020
Certification Date: 10/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

202 FARENHOLT AVE STE 101
TAMUNING GU
96913-3218
US

IV. Provider business mailing address

202 FARENHOLT AVE STE 101
TAMUNING GU
96913-3218
US

V. Phone/Fax

Practice location:
  • Phone: 671-646-1266
  • Fax: 671-646-1471
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPCY036
License Number StateGU
# 4
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code3336H0001X
TaxonomyHome Infusion Therapy Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: KEVIN GLICK
Title or Position: PRESIDENT
Credential: RPH
Phone: 808-245-1864