Provider Demographics
NPI:1649721994
Name:PRUDENCIO, JARRED B (PHARMD)
Entity type:Individual
Prefix:DR
First Name:JARRED
Middle Name:B
Last Name:PRUDENCIO
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 W KAWILI ST
Mailing Address - Street 2:
Mailing Address - City:HILO
Mailing Address - State:HI
Mailing Address - Zip Code:96720-4075
Mailing Address - Country:US
Mailing Address - Phone:808-937-2032
Mailing Address - Fax:
Practice Address - Street 1:45 MOHOULI ST STE 101
Practice Address - Street 2:
Practice Address - City:HILO
Practice Address - State:HI
Practice Address - Zip Code:96720-7210
Practice Address - Country:US
Practice Address - Phone:808-932-4215
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-21
Last Update Date:2016-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIPH-40211835P0018X, 1835P2201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
No1835P2201XPharmacy Service ProvidersPharmacistAmbulatory Care