Healthcare Provider Details

I. General information

NPI: 1447534573
Provider Name (Legal Business Name): ST MINA INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/07/2011
Last Update Date: 11/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8110 MANGO AVE STE 105
FONTANA CA
92335-3603
US

IV. Provider business mailing address

7643 CABRILLO WAY
EASTVALE CA
92880-0923
US

V. Phone/Fax

Practice location:
  • Phone: 909-350-3200
  • Fax: 909-350-3223
Mailing address:
  • Phone: 909-350-3200
  • Fax: 909-350-3223

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number50685
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: NADER ABADIER
Title or Position: SECRETARY/PHARMACIST
Credential:
Phone: 909-851-0311