Provider Demographics
NPI:1114301082
Name:MINA CORPORATION
Entity Type:Organization
Organization Name:MINA CORPORATION
Other - Org Name:MINA COMPOUNDING PHARMACY #4
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT,CEO
Authorized Official - Prefix:
Authorized Official - First Name:ADEL
Authorized Official - Middle Name:
Authorized Official - Last Name:ETINAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:808-222-9252
Mailing Address - Street 1:1620 N SCHOOL ST
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96817-1844
Mailing Address - Country:US
Mailing Address - Phone:808-672-6760
Mailing Address - Fax:808-356-3392
Practice Address - Street 1:1620 N SCHOOL ST
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96817-1844
Practice Address - Country:US
Practice Address - Phone:808-672-6760
Practice Address - Fax:808-356-3392
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-10
Last Update Date:2015-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
HIPHY-8883336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2152881OtherPK