Provider Demographics
NPI:1790494201
Name:PEGUESE, JEARLD
Entity Type:Individual
Prefix:
First Name:JEARLD
Middle Name:
Last Name:PEGUESE
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 1:111A PUIWA RD
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96817-1171
Mailing Address - Country:US
Mailing Address - Phone:808-721-6605
Mailing Address - Fax:
Practice Address - Street 1:1121 S BERETANIA ST
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96814-1621
Practice Address - Country:US
Practice Address - Phone:808-593-0403
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-23
Last Update Date:2022-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIPH-4854-0183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist