Provider Demographics
NPI:1851395289
Name:WALLACE-JONES, INC
Entity Type:Organization
Organization Name:WALLACE-JONES, INC
Other - Org Name:HAIKU PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT, PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:808-575-7522
Mailing Address - Street 1:810 HAIKU RD
Mailing Address - Street 2:STE 127
Mailing Address - City:HAIKU
Mailing Address - State:HI
Mailing Address - Zip Code:96708-4800
Mailing Address - Country:US
Mailing Address - Phone:808-575-7522
Mailing Address - Fax:808-575-2198
Practice Address - Street 1:810 HAIKU RD
Practice Address - Street 2:STE 127
Practice Address - City:HAIKU
Practice Address - State:HI
Practice Address - Zip Code:96708-4800
Practice Address - Country:US
Practice Address - Phone:808-575-7522
Practice Address - Fax:808-575-2198
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-13
Last Update Date:2008-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIPHY-567333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI07918801Medicaid
HI4123740001Medicare NSC