Provider Demographics
NPI:1285041319
Name:WAILEA PHARMACY LLC
Entity Type:Organization
Organization Name:WAILEA PHARMACY LLC
Other - Org Name:WAILEA PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:FARAH
Authorized Official - Middle Name:
Authorized Official - Last Name:MIKHAIL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:808-927-3426
Mailing Address - Street 1:34 WAILEA GATEWAY PL # A103
Mailing Address - Street 2:
Mailing Address - City:WAILEA
Mailing Address - State:HI
Mailing Address - Zip Code:96753-6525
Mailing Address - Country:US
Mailing Address - Phone:808-879-0123
Mailing Address - Fax:808-879-2345
Practice Address - Street 1:34 WAILEA GATEWAY PL STE A103
Practice Address - Street 2:
Practice Address - City:WAILEA
Practice Address - State:HI
Practice Address - Zip Code:96753-6525
Practice Address - Country:US
Practice Address - Phone:808-879-0123
Practice Address - Fax:808-879-2345
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-21
Last Update Date:2016-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIPHY-8553336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2147004OtherPK