Provider Demographics
NPI:1801249362
Name:CERRA, DOMINIC (PHARM BS)
Entity type:Individual
Prefix:
First Name:DOMINIC
Middle Name:
Last Name:CERRA
Suffix:
Gender:M
Credentials:PHARM BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:681 IMIHALE ST
Mailing Address - Street 2:
Mailing Address - City:KIHEI
Mailing Address - State:HI
Mailing Address - Zip Code:96753-6057
Mailing Address - Country:US
Mailing Address - Phone:949-235-6951
Mailing Address - Fax:
Practice Address - Street 1:681 IMIHALE ST
Practice Address - Street 2:
Practice Address - City:KIHEI
Practice Address - State:HI
Practice Address - Zip Code:96753-6057
Practice Address - Country:US
Practice Address - Phone:949-235-6951
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-20
Last Update Date:2016-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIPH 3951183500000X
CA44776183500000X
PARP0356691183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist