Provider Demographics
NPI:1144369273
Name:MEDIPHARM PHARMACY
Entity type:Organization
Organization Name:MEDIPHARM PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER,PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:808-523-7088
Mailing Address - Street 1:1188 BISHOP ST
Mailing Address - Street 2:802
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96813-3301
Mailing Address - Country:US
Mailing Address - Phone:808-523-7088
Mailing Address - Fax:808-523-7090
Practice Address - Street 1:1188 BISHOP ST
Practice Address - Street 2:SUITE #802
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96813-3301
Practice Address - Country:US
Practice Address - Phone:808-523-7088
Practice Address - Fax:808-523-7090
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-05
Last Update Date:2020-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIPH1976183500000X
3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI539116Medicaid