Provider Demographics
NPI:1205381803
Name:PAHOA PHARMACY LLC
Entity Type:Organization
Organization Name:PAHOA PHARMACY LLC
Other - Org Name:PAHOA PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER, PIC, AO
Authorized Official - Prefix:
Authorized Official - First Name:ISMAIL
Authorized Official - Middle Name:
Authorized Official - Last Name:ABDOLAHI
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:808-494-8960
Mailing Address - Street 1:PO BOX 11
Mailing Address - Street 2:15-2660 PAHOA VILLAGE ROAD SUITE 205
Mailing Address - City:PAHOA
Mailing Address - State:HI
Mailing Address - Zip Code:96778-0011
Mailing Address - Country:US
Mailing Address - Phone:808-965-0601
Mailing Address - Fax:808-965-0603
Practice Address - Street 1:15-2660 PAHOA VILLAGE RD
Practice Address - Street 2:
Practice Address - City:PAHOA
Practice Address - State:HI
Practice Address - Zip Code:96778-6720
Practice Address - Country:US
Practice Address - Phone:808-965-0601
Practice Address - Fax:808-965-0603
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-24
Last Update Date:2017-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
HIPHY-9093336C0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2166589OtherPK