Healthcare Provider Details

I. General information

NPI: 1003984246
Provider Name (Legal Business Name): QUEENS DEVELOPMENT CORPORATION & SUBSIDIARIES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/04/2006
Last Update Date: 07/20/2023
Certification Date: 07/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 S BERETANIA ST STE 102
HONOLULU HI
96813-2414
US

IV. Provider business mailing address

550 S BERETANIA ST STE 102
HONOLULU HI
96813-2414
US

V. Phone/Fax

Practice location:
  • Phone: 808-691-8925
  • Fax: 808-691-8926
Mailing address:
  • Phone: 808-691-8925
  • Fax: 808-691-8926

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License NumberPHY679
License Number StateHI
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: GAVIN SANJUME
Title or Position: DIR, RETAIL & CONTRCT PHCY
Credential: PHARMD
Phone: 808-691-4342