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MINA PHARMACY #11
CH09341C KOKUA KALIHI VALLEY COMPREHENSIVE FAMILY SERVICES
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Covered Entity Details
Entity Name
KOKUA KALIHI VALLEY COMPREHENSIVE FAMILY SERVICES
Subdivision Name
KKV Wellness Center
Type
HRSA-Funded Health Center
340B ID
CH09341C
Entity Address
2229 N School St
Honolulu, HI 96819-2588
Grant Number
H80CS00776
Participating Start Date
10/1/2014
Last Recertification Date
2/18/2025
Pharmacy Details
Pharmacy Name
MINA PHARMACY #11
Pharmacy Address
1401 SOUTH BERETANIA STREET
SUITE 110
HONOLULU, HI 96814
Pharmacy Comments
Contract Details
Approval Date
10/1/2014
Contract Begin Date
1/1/2015
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/22/2015
Ownership change
Contacts
Covered Entity Signing Official
DAVID DERAUF, Executive Director
(808) 791-9415
Contract Pharmacy Representative
Adel Etinas, President, CEO
(808) 738-4540
Signed By Date
10/1/2014
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