=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457416059
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WELLNESS PHARMACY INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/26/2006
-----------------------------------------------------
Last Update Date | 05/04/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 100 N BERETANIA ST SUITE 148
-----------------------------------------------------
City | HONOLULU
-----------------------------------------------------
State | HI
-----------------------------------------------------
Zip | 96817-4712
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 808-550-2833
-----------------------------------------------------
Fax | 808-550-2832
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 100 N BERETANIA ST SUITE 148
-----------------------------------------------------
City | HONOLULU
-----------------------------------------------------
State | HI
-----------------------------------------------------
Zip | 96817-4712
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 808-550-2833
-----------------------------------------------------
Fax | 808-550-2832
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | HENRY QUAN
-----------------------------------------------------
Credential | RPH
-----------------------------------------------------
Telephone | 808-550-2833
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | PHY602
-----------------------------------------------------
License Number State | HI
-----------------------------------------------------