Healthcare Provider Details

I. General information

NPI: 1487792693
Provider Name (Legal Business Name): LOREN LEE WILSON RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/01/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1010 PENSACOLA ST
HONOLULU HI
96814-2118
US

IV. Provider business mailing address

1287 ULUPALAKUA ST
KAILUA HI
96734-4349
US

V. Phone/Fax

Practice location:
  • Phone: 808-432-2065
  • Fax:
Mailing address:
  • Phone: 808-262-3987
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPH-618
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: