Provider Demographics
NPI:1407908197
Name:MIYAMOTO, TERRI
Entity Type:Individual
Prefix:
First Name:TERRI
Middle Name:
Last Name:MIYAMOTO
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 1:500 LUNALILO HOME RD
Mailing Address - Street 2:#12-J
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96825-1752
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2828 PAA ST
Practice Address - Street 2:THIRD FLOOR
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96819-4405
Practice Address - Country:US
Practice Address - Phone:808-432-5646
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIPH-2307183500000X
WAPH00041363183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist