Provider Demographics
NPI:1477102655
Name:MULLAHY, MATHEW GEORGE
Entity Type:Individual
Prefix:
First Name:MATHEW
Middle Name:GEORGE
Last Name:MULLAHY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:645 ALEKA LOOP
Mailing Address - Street 2:
Mailing Address - City:KAPAA
Mailing Address - State:HI
Mailing Address - Zip Code:96746-1459
Mailing Address - Country:US
Mailing Address - Phone:808-822-4918
Mailing Address - Fax:808-821-2191
Practice Address - Street 1:645 ALEKA LOOP
Practice Address - Street 2:
Practice Address - City:KAPAA
Practice Address - State:HI
Practice Address - Zip Code:96746-1459
Practice Address - Country:US
Practice Address - Phone:808-822-4918
Practice Address - Fax:808-821-2191
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-10
Last Update Date:2019-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI3541183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist