Provider Demographics
NPI:1104992650
Name:MUDRICK, CARL PHILLIP (RPH)
Entity type:Individual
Prefix:MR
First Name:CARL
Middle Name:PHILLIP
Last Name:MUDRICK
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 1:2011 COYNE ST
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96826-1334
Mailing Address - Country:US
Mailing Address - Phone:808-946-0064
Mailing Address - Fax:808-949-7131
Practice Address - Street 1:2011 COYNE ST
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96826-1334
Practice Address - Country:US
Practice Address - Phone:808-946-0064
Practice Address - Fax:808-949-7131
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIPH1636183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist