Provider Demographics
NPI:1104962463
Name:OUTRIGGER SHOPS LTD
Entity type:Organization
Organization Name:OUTRIGGER SHOPS LTD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OWNER OF THE COMPANY
Authorized Official - Prefix:MR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:G
Authorized Official - Last Name:NORSTROM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:808-923-2057
Mailing Address - Street 1:2330 KUHIO AVE
Mailing Address - Street 2:MEZZANINE FLOOR
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96815-2951
Mailing Address - Country:US
Mailing Address - Phone:808-923-4466
Mailing Address - Fax:808-922-1104
Practice Address - Street 1:2330 KUHIO AVE
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96815-2951
Practice Address - Country:US
Practice Address - Phone:808-923-4466
Practice Address - Fax:808-922-1104
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIPHY200333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI08186101Medicaid
HIP0007778OtherHMSA