Provider Demographics
NPI:1912983065
Name:ISLA HOME INFUSION INC.
Entity Type:Organization
Organization Name:ISLA HOME INFUSION INC.
Other - Org Name:ISLA HOME INFUSION INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:GLICK
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:808-245-1864
Mailing Address - Street 1:202 FARENHOLT AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:TAMUNING
Mailing Address - State:GU
Mailing Address - Zip Code:96913-3218
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:202 FARENHOLT AVE STE 101
Practice Address - Street 2:
Practice Address - City:TAMUNING
Practice Address - State:GU
Practice Address - Zip Code:96913-3218
Practice Address - Country:US
Practice Address - Phone:671-646-1266
Practice Address - Fax:671-646-1471
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-21
Last Update Date:2020-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336C0004X, 3336H0001X
GUPCY0363336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
5428936OtherNCPDP PROVIDER IDENTIFICATION NUMBER
1192740001Medicare NSC