1497859441 NPI number — MINIMS APOTHECARY LLC, DBA BANETH'S PHARMACY

Table of content: (NPI 1497859441)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497859441 NPI number — MINIMS APOTHECARY LLC, DBA BANETH'S PHARMACY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MINIMS APOTHECARY LLC, DBA BANETH'S PHARMACY
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1497859441
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/24/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
900 WILLOW RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MENLO PARK
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94025-2544
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
650-326-8400
Provider Business Mailing Address Fax Number:
650-323-2609

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
900 WILLOW RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MENLO PARK
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94025-2544
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
650-326-8400
Provider Business Practice Location Address Fax Number:
650-323-2609
Provider Enumeration Date:
09/12/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
MAHMOUD-THIRUCOTE
Authorized Official First Name:
SAGEDA
Authorized Official Middle Name:
Authorized Official Title or Position:
PHARMACIST - IN - CHARGE
Authorized Official Telephone Number:
650-326-8400

Provider Taxonomy Codes

  • Taxonomy code: 333600000X , with the licence number:  PHY46536 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0004X , with the licence number: PHY48368 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0523123 . This is a "OTHER ID NUMBER-COMMERCIAL NUMBER" identifier . This identifiers is of the category "OTHER".
  • Identifier: PHA465360 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".