Healthcare Provider Details

I. General information

NPI: 1285024794
Provider Name (Legal Business Name): FOODLAND LAB #28
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/04/2015
Last Update Date: 02/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4-771 KUHIO HWY STE 101
KAPAA HI
96746-2719
US

IV. Provider business mailing address

4-771 KUHIO HWY STE 101
KAPAA HI
96746-2719
US

V. Phone/Fax

Practice location:
  • Phone: 808-821-6979
  • Fax: 808-821-6977
Mailing address:
  • Phone: 808-821-6979
  • Fax: 808-821-6977

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number14-CP1-358
License Number StateHI

VIII. Authorized Official

Name: JACLYN MOORE
Title or Position: LAB DIRECTOR
Credential: PHARM D
Phone: 808-885-2075