Provider Demographics
NPI:1245231851
Name:QUEEN'S DEVELOPMENT CORPORATION & SUBSIDIARIES
Entity Type:Organization
Organization Name:QUEEN'S DEVELOPMENT CORPORATION & SUBSIDIARIES
Other - Org Name:QUEEN'S POB II PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:GAVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:SANJUME
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:808-691-4342
Mailing Address - Street 1:1329 LUSITANA ST STE 101
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96813-2401
Mailing Address - Country:US
Mailing Address - Phone:808-691-4560
Mailing Address - Fax:808-691-4072
Practice Address - Street 1:1329 LUSITANA ST
Practice Address - Street 2:STE 101
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96813-2429
Practice Address - Country:US
Practice Address - Phone:808-691-4560
Practice Address - Fax:808-691-4072
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:QUEEN'S DEVELOPMENT CORPORATION & SUBSIDIARIES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-08-04
Last Update Date:2019-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIPHY-465332B00000X, 332BD1200X, 332BN1400X, 332BP3500X, 333600000X, 335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BD1200XSuppliersDurable Medical Equipment & Medical SuppliesDialysis Equipment & Supplies
No332BN1400XSuppliersDurable Medical Equipment & Medical SuppliesNursing Facility Supplies
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
No335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI1202578OtherNCPDP NUMBER
HI085381-01Medicaid
HI1202578OtherNABP NUMBER
HI1202578OtherNABP NUMBER