Healthcare Provider Details

I. General information

NPI: 1730439779
Provider Name (Legal Business Name): MARI-MINA PHARMACEUTICALS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/18/2012
Last Update Date: 12/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10374 TRADEMARK ST
RANCHO CUCAMONGA CA
91730-5824
US

IV. Provider business mailing address

10374 TRADEMARK ST
RANCHO CUCAMONGA CA
91730-5824
US

V. Phone/Fax

Practice location:
  • Phone: 909-477-6300
  • Fax: 909-477-3009
Mailing address:
  • Phone: 909-477-6300
  • Fax: 909-477-3009

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 TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code3336H0001X
TaxonomyHome Infusion Therapy Pharmacy
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number50935
License Number StateCA

VIII. Authorized Official

Name: NOHA KOLTA
Title or Position: PIC
Credential:
Phone: 909-477-6300