Provider Demographics
NPI: | 1760872261 |
---|---|
Name: | FOODLAND LAB #38 |
Entity Type: | Organization |
Organization Name: | FOODLAND LAB #38 |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | LAB DIRECTOR |
Authorized Official - Prefix: | |
Authorized Official - First Name: | JACLYN |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | MOORE |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | PHARMD |
Authorized Official - Phone: | 808-885-2075 |
Mailing Address - Street 1: | 67-1185 MAMALAHOA HWY |
Mailing Address - Street 2: | |
Mailing Address - City: | KAMUELA |
Mailing Address - State: | HI |
Mailing Address - Zip Code: | 96743-7304 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 808-885-2075 |
Mailing Address - Fax: | 808-885-2061 |
Practice Address - Street 1: | 67-1185 MAMALAHOA HWY |
Practice Address - Street 2: | |
Practice Address - City: | KAMUELA |
Practice Address - State: | HI |
Practice Address - Zip Code: | 96743-7304 |
Practice Address - Country: | US |
Practice Address - Phone: | 808-885-2075 |
Practice Address - Fax: | 808-885-2061 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | Yes |
Parent Organization LBN: | FOODLAND SUPERMARKET LTD. |
Parent Organization TIN: | <UNAVAIL> |
Enumeration Date: | 2015-02-04 |
Last Update Date: | 2015-02-04 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
HI | 14-CP1-362 | 291U00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 291U00000X | Laboratories | Clinical Medical Laboratory |