Provider Demographics
NPI:1720476096
Name:LYU, SORA
Entity Type:Individual
Prefix:
First Name:SORA
Middle Name:
Last Name:LYU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325A OLOKANI ST
Mailing Address - Street 2:
Mailing Address - City:MAKAWAO
Mailing Address - State:HI
Mailing Address - Zip Code:96768-8002
Mailing Address - Country:US
Mailing Address - Phone:406-696-7757
Mailing Address - Fax:
Practice Address - Street 1:53 S PUUNENE AVE
Practice Address - Street 2:
Practice Address - City:KAHULUI
Practice Address - State:HI
Practice Address - Zip Code:96732-2192
Practice Address - Country:US
Practice Address - Phone:406-696-7757
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-08
Last Update Date:2015-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIPH-3775183500000X
IN26025735A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist