Healthcare Provider Details

I. General information

NPI: 1245231851
Provider Name (Legal Business Name): QUEEN'S DEVELOPMENT CORPORATION & SUBSIDIARIES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/04/2005
Last Update Date: 07/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1329 LUSITANA ST STE 101
HONOLULU HI
96813-2429
US

IV. Provider business mailing address

1329 LUSITANA ST STE 101
HONOLULU HI
96813-2401
US

V. Phone/Fax

Practice location:
  • Phone: 808-691-4560
  • Fax: 808-691-4072
Mailing address:
  • Phone: 808-691-4560
  • Fax: 808-691-4072

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License NumberPHY-465
License Number StateHI
# 2
Primary TaxonomyN
Taxonomy Code332BD1200X
TaxonomyDialysis Equipment & Supplies (DME)
License NumberPHY-465
License Number StateHI
# 3
Primary TaxonomyN
Taxonomy Code332BN1400X
TaxonomyNursing Facility Supplies (DME)
License NumberPHY-465
License Number StateHI
# 4
Primary TaxonomyN
Taxonomy Code332BP3500X
TaxonomyParenteral & Enteral Nutrition Supplies (DME)
License NumberPHY-465
License Number StateHI
# 5
Primary TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License NumberPHY-465
License Number StateHI
# 6
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License NumberPHY-465
License Number StateHI

VIII. Authorized Official

Name: DR. GAVIN SANJUME
Title or Position: DIRECTOR
Credential: PHARM.D.
Phone: 808-691-4342