Provider Demographics
NPI:1861407249
Name:CTIY PHARMACY KAPAHULU, INC.
Entity type:Organization
Organization Name:CTIY PHARMACY KAPAHULU, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST-MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:CARL
Authorized Official - Middle Name:PHILLIP
Authorized Official - Last Name:MUDRICK
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:808-739-1188
Mailing Address - Street 1:750 PALANI AVE
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96816-1109
Mailing Address - Country:US
Mailing Address - Phone:808-739-1188
Mailing Address - Fax:808-735-6545
Practice Address - Street 1:750 PALANI AVE
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96816-1109
Practice Address - Country:US
Practice Address - Phone:808-739-1188
Practice Address - Fax:808-735-6545
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIPHY5153336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI00445401Medicaid