Basic Information
| Provider Information | |||||||||
| NPI: | 1477102655 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MULLAHY | ||||||||
| FirstName: | MATHEW | ||||||||
| MiddleName: | GEORGE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 645 ALEKA LOOP | ||||||||
| Address2: | |||||||||
| City: | KAPAA | ||||||||
| State: | HI | ||||||||
| PostalCode: | 967461459 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8088224918 | ||||||||
| FaxNumber: | 8088212191 | ||||||||
| Practice Location | |||||||||
| Address1: | 645 ALEKA LOOP | ||||||||
| Address2: | |||||||||
| City: | KAPAA | ||||||||
| State: | HI | ||||||||
| PostalCode: | 967461459 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8088224918 | ||||||||
| FaxNumber: | 8088212191 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/10/2019 | ||||||||
| LastUpdateDate: | 09/10/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | 3541 | HI | Y | Pharmacy Service Providers | Pharmacist |
No ID Information.