Healthcare Provider Details

I. General information

NPI: 1225073083
Provider Name (Legal Business Name): MARIOMINA INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/17/2006
Last Update Date: 01/18/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

820 W SAN BERNARDINO RD
COVINA CA
91722-3622
US

IV. Provider business mailing address

820 W SAN BERNARDINO RD
COVINA CA
91722-3622
US

V. Phone/Fax

Practice location:
  • Phone: 626-446-6088
  • Fax: 626-446-9399
Mailing address:
  • Phone: 626-446-6088
  • Fax: 626-446-9399

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPHY54605
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: MAGED BESHAY
Title or Position: PHARMACIST IN CHARGE
Credential:
Phone: 909-837-8560