Healthcare Provider Details

I. General information

NPI: 1578062865
Provider Name (Legal Business Name): TIFFANY MIZO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/02/2018
Last Update Date: 02/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

47-047 KAMEHAMEHA HWY
KANEOHE HI
96744-4731
US

IV. Provider business mailing address

46-047 KAMEHAMEHA HWY
KANEOHE HI
96744-3736
US

V. Phone/Fax

Practice location:
  • Phone: 808-235-4551
  • Fax:
Mailing address:
  • Phone: 808-235-4551
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPH3710
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: