Healthcare Provider Details

I. General information

NPI: 1740548981
Provider Name (Legal Business Name): MINA PHARMACY LTC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/25/2012
Last Update Date: 05/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

275 W. KAAHUMANU AVE #1C01
KAHULUI HI
96732
US

IV. Provider business mailing address

3375 KOAPAKA STREET F245
HONOLULU HI
96819
US

V. Phone/Fax

Practice location:
  • Phone: 808-856-3070
  • Fax: 808-442-9635
Mailing address:
  • Phone: 808-738-4540
  • Fax: 808-690-9174

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPHY-813
License Number StateHI

VIII. Authorized Official

Name: ADEL ETINAS
Title or Position: PRESIDENT
Credential: RPH
Phone: 808-738-4540