Contract Pharmacy Details

MINA PHARMACY #11
FP968194 KOKUA KALIHI VALLEY

Covered Entity Details

Entity Name

KOKUA KALIHI VALLEY

Subdivision Name

Type

Family Planning (Title X only)

340B ID

FP968194

Entity Address

2239 NORTH SCHOOL ST
HONOLULU, HI 96819

Grant Number

FPHPA090326

Participating Start Date

1/1/1998

Last Recertification Date

5/13/2022

Entity Termination Date

7/1/2023

Pharmacy Details

Pharmacy Name

MINA PHARMACY #11

Pharmacy Address

1401 SOUTH BERETANIA STREET
SUITE 110
HONOLULU, HI 96814

Pharmacy Comments

Contract Details

Approval Date

4/2/2015

Contract Begin Date

7/1/2015

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

4/22/2015
Ownership change

Contacts

Covered Entity Signing Official

Laura DeVilbiss, Medical Director
(808) 791-9418

Contract Pharmacy Representative

Adel Etinas, President, CEO
(808) 738-4540

Signed By Date

4/2/2015