Healthcare Provider Details

I. General information

NPI: 1922366079
Provider Name (Legal Business Name): MINA PHARMACY LTC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/26/2012
Last Update Date: 04/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

275 W KAAHUMANU AVE STE 1C01A
KAHULUI HI
96732-1629
US

IV. Provider business mailing address

3375 KOAPAKA ST STE F245
HONOLULU HI
96819-1881
US

V. Phone/Fax

Practice location:
  • Phone: 808-856-8030
  • Fax: 808-442-9634
Mailing address:
  • Phone: 808-738-4540
  • Fax: 808-690-9174

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336I0012X
TaxonomyInstitutional Pharmacy
License NumberPHY-812
License Number StateHI

VIII. Authorized Official

Name: TIMOTHY MOSER
Title or Position: DIRECTOR OF PHARMACY
Credential:
Phone: 808-738-4540