Provider Demographics
NPI:1629302773
Name:UNIVERSITY OF HAWAII AT MANOA
Entity Type:Organization
Organization Name:UNIVERSITY OF HAWAII AT MANOA
Other - Org Name:UNIVERSITY OF HAWAII AT HILO STUDENT MEDICAL SERVICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:MIMI
Authorized Official - Middle Name:
Authorized Official - Last Name:PEZZUTO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:808-932-7369
Mailing Address - Street 1:200 W KAWILI ST
Mailing Address - Street 2:
Mailing Address - City:HILO
Mailing Address - State:HI
Mailing Address - Zip Code:96720-4075
Mailing Address - Country:US
Mailing Address - Phone:808-932-7369
Mailing Address - Fax:
Practice Address - Street 1:200 W KAWILI ST
Practice Address - Street 2:
Practice Address - City:HILO
Practice Address - State:HI
Practice Address - Zip Code:96720-4075
Practice Address - Country:US
Practice Address - Phone:808-932-7369
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-22
Last Update Date:2014-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
HIPHY-8323336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
2143166OtherPK