Provider Demographics
NPI:1851401921
Name:J.G.N.A. CORP
Entity Type:Organization
Organization Name:J.G.N.A. CORP
Other - Org Name:D.A. PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:JE
Authorized Official - Last Name:FONG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:808-293-1600
Mailing Address - Street 1:55-510 KAMEHAMEHA HWY
Mailing Address - Street 2:SUITE 13
Mailing Address - City:LAIE
Mailing Address - State:HI
Mailing Address - Zip Code:96762-1138
Mailing Address - Country:US
Mailing Address - Phone:808-293-1600
Mailing Address - Fax:
Practice Address - Street 1:55-510 KAMEHAMEHA HWY
Practice Address - Street 2:SUITE 13
Practice Address - City:LAIE
Practice Address - State:HI
Practice Address - Zip Code:96762-1138
Practice Address - Country:US
Practice Address - Phone:808-293-1600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIPHY-5533336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI07501901Medicaid
1203506OtherNABP
1203506OtherNABP