Provider Demographics
NPI:1295375228
Name:NISHIMURA, ROGER T
Entity type:Individual
Prefix:
First Name:ROGER
Middle Name:T
Last Name:NISHIMURA
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 1:98-1556 HOOMAHILU ST
Mailing Address - Street 2:
Mailing Address - City:PEARL CITY
Mailing Address - State:HI
Mailing Address - Zip Code:96782-2323
Mailing Address - Country:US
Mailing Address - Phone:808-733-2035
Mailing Address - Fax:
Practice Address - Street 1:1173 21ST AVE
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96816-4637
Practice Address - Country:US
Practice Address - Phone:808-733-2035
Practice Address - Fax:808-733-2462
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-07
Last Update Date:2020-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI875183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist