Provider Demographics
NPI:1104316215
Name:GLICK, KEVIN CRAIG (RPH)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:CRAIG
Last Name:GLICK
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4491A KOLOPA ST
Mailing Address - Street 2:
Mailing Address - City:LIHUE
Mailing Address - State:HI
Mailing Address - Zip Code:96766-2034
Mailing Address - Country:US
Mailing Address - Phone:808-246-9100
Mailing Address - Fax:
Practice Address - Street 1:4491A KOLOPA ST
Practice Address - Street 2:
Practice Address - City:LIHUE
Practice Address - State:HI
Practice Address - Zip Code:96766-2034
Practice Address - Country:US
Practice Address - Phone:808-246-9100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-14
Last Update Date:2018-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIPH7971835P2201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P2201XPharmacy Service ProvidersPharmacistAmbulatory Care