Provider Demographics
NPI:1700464583
Name:TABOADA, JERRICK (PHARMD)
Entity Type:Individual
Prefix:
First Name:JERRICK
Middle Name:
Last Name:TABOADA
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 1:94-502 LOAA ST
Mailing Address - Street 2:
Mailing Address - City:WAIPAHU
Mailing Address - State:HI
Mailing Address - Zip Code:96797-1510
Mailing Address - Country:US
Mailing Address - Phone:808-234-3952
Mailing Address - Fax:
Practice Address - Street 1:94-216 FARRINGTON HWY STE 102
Practice Address - Street 2:
Practice Address - City:WAIPAHU
Practice Address - State:HI
Practice Address - Zip Code:96797-1900
Practice Address - Country:US
Practice Address - Phone:808-677-5550
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-01
Last Update Date:2021-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIPH-4488183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist