Basic Information
| Provider Information | |||||||||
| NPI: | 1861481046 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SANJUME | ||||||||
| FirstName: | TRACIE | ||||||||
| MiddleName: | L. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PHARMD, BCPS, CDCES | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SHIMIZU | ||||||||
| OtherFirstName: | TRACIE | ||||||||
| OtherMiddleName: | L. | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PHARMD, BCPS, CDCES | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | NAVAL HEALTH CLINIC HAWAII | ||||||||
| Address2: | 480 CENTRAL AVENUE | ||||||||
| City: | PEARL HARBOR | ||||||||
| State: | HI | ||||||||
| PostalCode: | 968604908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8084731880 | ||||||||
| FaxNumber: | 8084734449 | ||||||||
| Practice Location | |||||||||
| Address1: | 480 CENTRAL AVE | ||||||||
| Address2: | |||||||||
| City: | JBPHH | ||||||||
| State: | HI | ||||||||
| PostalCode: | 968604908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8084731880 | ||||||||
| FaxNumber: | 8084734449 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2005 | ||||||||
| LastUpdateDate: | 09/29/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1835P1200X | 53772 | CA | N | Pharmacy Service Providers | Pharmacist | Pharmacotherapy | 1835P1200X | 2349 | HI | N | Pharmacy Service Providers | Pharmacist | Pharmacotherapy | 1835P2201X | 53772 | CA | N | 1835P2201X | 2349 | HI | Y |
No ID Information.