Provider Demographics
NPI:1710066303
Name:NAN KULI KAI PHARMACY INC
Entity Type:Organization
Organization Name:NAN KULI KAI PHARMACY INC
Other - Org Name:WAIKOLOA PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CORP PRES V PRES
Authorized Official - Prefix:MRS
Authorized Official - First Name:BONNIE
Authorized Official - Middle Name:G
Authorized Official - Last Name:PREBULA
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:808-965-5629
Mailing Address - Street 1:PO BOX 385001
Mailing Address - Street 2:
Mailing Address - City:WAIKOLOA
Mailing Address - State:HI
Mailing Address - Zip Code:96738-5001
Mailing Address - Country:US
Mailing Address - Phone:808-883-8484
Mailing Address - Fax:808-883-8871
Practice Address - Street 1:68 1845 WAIKOLOA ROAD
Practice Address - Street 2:#113
Practice Address - City:WAIKOLOA
Practice Address - State:HI
Practice Address - Zip Code:96738-5001
Practice Address - Country:US
Practice Address - Phone:808-883-8484
Practice Address - Fax:808-883-8871
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-03
Last Update Date:2008-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIPHY499183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI00102301Medicaid
B80057OtherHMSA
B80057OtherHMSA