Provider Demographics
NPI:1013305457
Name:MEDIPHARM PHARMACY LLC
Entity Type:Organization
Organization Name:MEDIPHARM PHARMACY LLC
Other - Org Name:MEDIPHARM PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:
Authorized Official - Last Name:DAHLEM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:808-523-7088
Mailing Address - Street 1:PO BOX 38029
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96837-1029
Mailing Address - Country:US
Mailing Address - Phone:808-561-9647
Mailing Address - Fax:808-523-7088
Practice Address - Street 1:891 ULULANI ST STE 113
Practice Address - Street 2:
Practice Address - City:HILO
Practice Address - State:HI
Practice Address - Zip Code:96720-3982
Practice Address - Country:US
Practice Address - Phone:808-969-9163
Practice Address - Fax:808-969-9263
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-08
Last Update Date:2020-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336L0003X
HIPHY8703336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI539116Medicaid
2149431OtherPK