=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497859441
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MINIMS APOTHECARY LLC, DBA BANETH'S PHARMACY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/12/2006
-----------------------------------------------------
Last Update Date | 03/24/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 900 WILLOW RD
-----------------------------------------------------
City | MENLO PARK
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94025-2544
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 650-326-8400
-----------------------------------------------------
Fax | 650-323-2609
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 900 WILLOW RD
-----------------------------------------------------
City | MENLO PARK
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94025-2544
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 650-326-8400
-----------------------------------------------------
Fax | 650-323-2609
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHARMACIST - IN - CHARGE
-----------------------------------------------------
Name | MS. SAGEDA MAHMOUD-THIRUCOTE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 650-326-8400
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number | PHY46536
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 3336C0004X
-----------------------------------------------------
Taxonomy Name | Compounding Pharmacy
-----------------------------------------------------
License Number | PHY48368
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------