Healthcare Provider Details

I. General information

NPI: 1912024209
Provider Name (Legal Business Name): MEDIPHARM PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/23/2007
Last Update Date: 08/15/2023
Certification Date: 08/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

197 SAND ISLAND ACCESS RD STE 208
HONOLULU HI
96819-4901
US

IV. Provider business mailing address

PO BOX 38029
HONOLULU HI
96837-1029
US

V. Phone/Fax

Practice location:
  • Phone: 808-744-9080
  • Fax: 808-744-9079
Mailing address:
  • Phone: 808-791-6077
  • Fax: 808-791-6076

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License NumberPHY689
License Number StateHI
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: SCOTT KIM
Title or Position: PHRM
Credential:
Phone: 808-523-7088