Provider Demographics
NPI:1427789965
Name:WATANABE, GREG MATAO
Entity type:Individual
Prefix:
First Name:GREG
Middle Name:MATAO
Last Name:WATANABE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:94-482 PUNONO ST
Mailing Address - Street 2:
Mailing Address - City:MILILANI
Mailing Address - State:HI
Mailing Address - Zip Code:96789-2567
Mailing Address - Country:US
Mailing Address - Phone:808-388-6678
Mailing Address - Fax:
Practice Address - Street 1:99-128 AIEA HEIGHTS DR STE 103
Practice Address - Street 2:
Practice Address - City:AIEA
Practice Address - State:HI
Practice Address - Zip Code:96701-3916
Practice Address - Country:US
Practice Address - Phone:808-840-5681
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-23
Last Update Date:2022-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIPH-4759183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist