MEDICARE: MINA PHARMACY LTC, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3336L0003X	Long Term Care Pharmacy	PHY-693	HI

General Provider Information

NPI Number	:	1255453676
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MINA PHARMACY LTC, LLC

Provider Business Mailing Address
First Line	:	3375 KOAPAKA STREET
Second Line	:	SUITE F245
City	:	HONOLULU
State	:	HI
Zip	:	96819-1816
Country	:	US
Telephone Number	:	808-738-4540
Fax Number	:	808-690-9174

Provider Business Practice Location Address
First Line	:	4510 SALT LAKE BLVD
Second Line	:	#B7-A
City	:	HONOLULU
State	:	HI
Zip	:	96818-3171
Country	:	US
Telephone Number	:	808-488-7500
Fax Number	:	808-488-7505

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. ADEL ETINAS
Credential	:	R.PH.
Telephone Number	:	808-738-4540

Provider Enumeration Date	:	04/05/2007
Last Update Date	:	09/08/2011

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