1770750911 NPI number — MINA PHARMACY LTC, LLC

Table of content: (NPI 1770750911)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770750911 NPI number — MINA PHARMACY LTC, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MINA PHARMACY LTC, LLC
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:
6
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:
1770750911
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/08/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3375 KOAPAKA STREET
Provider Second Line Business Mailing Address:
SUITE F245
Provider Business Mailing Address City Name:
HONOLULU
Provider Business Mailing Address State Name:
HI
Provider Business Mailing Address Postal Code:
96819-1816
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
808-738-4540
Provider Business Mailing Address Fax Number:
808-690-9174

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1251 KILAUEA AVE
Provider Second Line Business Practice Location Address:
#190C-1
Provider Business Practice Location Address City Name:
HILO
Provider Business Practice Location Address State Name:
HI
Provider Business Practice Location Address Postal Code:
96720-8509
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
808-935-3100
Provider Business Practice Location Address Fax Number:
808-935-6800
Provider Enumeration Date:
05/15/2008

Additional Information

Authorized Official

Authorized Official Last Name:
ETINAS
Authorized Official First Name:
ADEL
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
808-738-4540

Provider Taxonomy Codes

  • Taxonomy code: 3336L0003X , with the licence number:  PHY707 , registered in the state of HI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1240124 . This is a "NCPDP PROVIDER IDENTIFICATION NUMBER" identifier . This identifiers is of the category "OTHER".




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