Provider Demographics
NPI:1144587627
Name:VALENCIA BOLOSAN, DOMINIQUE
Entity Type:Individual
Prefix:MRS
First Name:DOMINIQUE
Middle Name:
Last Name:VALENCIA BOLOSAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:142 IKEA PL
Mailing Address - Street 2:
Mailing Address - City:MAKAWAO
Mailing Address - State:HI
Mailing Address - Zip Code:96768-8716
Mailing Address - Country:US
Mailing Address - Phone:808-276-9188
Mailing Address - Fax:
Practice Address - Street 1:55 KIOPAA PL
Practice Address - Street 2:
Practice Address - City:MAKAWAO
Practice Address - State:HI
Practice Address - Zip Code:96768-8282
Practice Address - Country:US
Practice Address - Phone:808-573-9300
Practice Address - Fax:808-573-9309
Is Sole Proprietor?:No
Enumeration Date:2012-04-20
Last Update Date:2020-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAIR60240637183500000X
HIPH-3884183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist