Healthcare Provider Details

I. General information

NPI: 1013305457
Provider Name (Legal Business Name): MEDIPHARM PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/08/2015
Last Update Date: 10/11/2024
Certification Date: 10/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

891 ULULANI ST STE 113
HILO HI
96720-3982
US

IV. Provider business mailing address

PO BOX 38029
HONOLULU HI
96837-1029
US

V. Phone/Fax

Practice location:
  • Phone: 808-969-9163
  • Fax: 808-969-9263
Mailing address:
  • Phone: 808-744-9080
  • Fax: 808-744-9079

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPHY870
License Number StateHI
# 3
Primary TaxonomyY
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: SCOTT DAHLEM
Title or Position: OFFICE MANAGER
Credential:
Phone: 808-523-7088