Healthcare Provider Details

I. General information

NPI: 1154244101
Provider Name (Legal Business Name): INNOMINDS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/04/2026
Last Update Date: 08/04/2026
Certification Date: 08/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1215 E WASHINGTON AVE
UNION GAP WA
98903-1669
US

IV. Provider business mailing address

1215 E WASHINGTON AVE
UNION GAP WA
98903-1669
US

V. Phone/Fax

Practice location:
  • Phone: 509-823-1657
  • Fax: 509-823-1658
Mailing address:
  • Phone: 509-823-1657
  • Fax: 509-823-1658

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: MR. SRINIVASULU MANDAVA
Title or Position: PHARMACY MANAGER
Credential: RPH
Phone: 509-899-6021