Healthcare Provider Details

I. General information

NPI: 1487737094
Provider Name (Legal Business Name): MICHAEL S MINA R.PH.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/24/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3900 WOODLAND AVE
PHILADELPHIA PA
19104-4551
US

IV. Provider business mailing address

79 SCOTLAND DR
READING PA
19606-9051
US

V. Phone/Fax

Practice location:
  • Phone: 215-823-5844
  • Fax: 215-823-4407
Mailing address:
  • Phone: 610-406-0792
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number18976
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: