Provider Demographics
NPI:1427690270
Name:MAYURAL, CHANEL
Entity type:Individual
Prefix:
First Name:CHANEL
Middle Name:
Last Name:MAYURAL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CHANEL
Other - Middle Name:
Other - Last Name:OPUNUI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:87-762 MEAULU RD
Mailing Address - Street 2:
Mailing Address - City:WAIANAE
Mailing Address - State:HI
Mailing Address - Zip Code:96792-3243
Mailing Address - Country:US
Mailing Address - Phone:808-690-4767
Mailing Address - Fax:
Practice Address - Street 1:86-120 FARRINGTON HWY
Practice Address - Street 2:
Practice Address - City:WAIANAE
Practice Address - State:HI
Practice Address - Zip Code:96792-3000
Practice Address - Country:US
Practice Address - Phone:808-696-7059
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-14
Last Update Date:2019-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI3561183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist