Provider Demographics
NPI:1063830644
Name:FORMANACK, GREGORY (RPH)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:FORMANACK
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:77-104 KALANIUKA ST
Mailing Address - Street 2:
Mailing Address - City:HOLUALOA
Mailing Address - State:HI
Mailing Address - Zip Code:96725-9728
Mailing Address - Country:US
Mailing Address - Phone:808-326-1707
Mailing Address - Fax:
Practice Address - Street 1:74-5465 KAMAKAEHA AVE
Practice Address - Street 2:
Practice Address - City:KAILUA KONA
Practice Address - State:HI
Practice Address - Zip Code:96740-1648
Practice Address - Country:US
Practice Address - Phone:808-326-1707
Practice Address - Fax:808-334-1173
Is Sole Proprietor?:No
Enumeration Date:2014-04-01
Last Update Date:2014-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI1301183500000X
MT3046183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist