Provider Demographics
NPI:1386475564
Name:DUSTIN, MALIA KUULEI (PHARMD)
Entity type:Individual
Prefix:
First Name:MALIA
Middle Name:KUULEI
Last Name:DUSTIN
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:54 EVERMORE CT
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32084-0093
Mailing Address - Country:US
Mailing Address - Phone:208-994-1811
Mailing Address - Fax:
Practice Address - Street 1:1440 US HIGHWAY 1 S
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32084-4211
Practice Address - Country:US
Practice Address - Phone:904-824-7127
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-09
Last Update Date:2024-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS67465183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist