Provider Demographics
NPI:1083903264
Name:WELLNESS PHARMACY STORE 2 INC
Entity Type:Organization
Organization Name:WELLNESS PHARMACY STORE 2 INC
Other - Org Name:WELLNESS PHARMACY STORE #2
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:YIN PUN
Authorized Official - Middle Name:
Authorized Official - Last Name:WONG
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:808-550-2888
Mailing Address - Street 1:100 N BERETANIA ST
Mailing Address - Street 2:SUITE 148
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96817-4712
Mailing Address - Country:US
Mailing Address - Phone:808-550-2888
Mailing Address - Fax:808-550-2889
Practice Address - Street 1:1120 MAUNAKEA ST STE 102
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96817-5173
Practice Address - Country:US
Practice Address - Phone:808-550-2888
Practice Address - Fax:808-550-2889
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-29
Last Update Date:2017-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIPHY-801333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2129703OtherPK