Healthcare Provider Details

I. General information

NPI: 1750636080
Provider Name (Legal Business Name): MIINFA INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/24/2012
Last Update Date: 01/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14379 LIVERNOIS AVE
DETROIT MI
48238-2507
US

IV. Provider business mailing address

14379 LIVERNOIS AVE
DETROIT MI
48238-2507
US

V. Phone/Fax

Practice location:
  • Phone: 313-491-7450
  • Fax: 313-491-7451
Mailing address:
  • Phone: 313-491-7450
  • Fax: 313-491-7451

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number5301009873
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: MR. MUFUTAU ADEGUNLOLA
Title or Position: PHARMACY MANAGER
Credential: PHARMACIST
Phone: 313-491-7450