Healthcare Provider Details

I. General information

NPI: 1275894594
Provider Name (Legal Business Name): MINA CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/04/2012
Last Update Date: 01/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

440 KILANI AVE
WAHIAWA HI
96786-1837
US

IV. Provider business mailing address

3375 KOAPAKA ST STE F245
HONOLULU HI
96819-1881
US

V. Phone/Fax

Practice location:
  • Phone: 808-533-9020
  • Fax: 808-690-9189
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 NumberPHY814
License Number StateHI

VIII. Authorized Official

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