Provider Demographics
NPI:1184022188
Name:MINTWOOD PHARMACUETICALS, INC.
Entity Type:Organization
Organization Name:MINTWOOD PHARMACUETICALS, INC.
Other - Org Name:MINTWOOD PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT & PIC
Authorized Official - Prefix:
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:
Authorized Official - Last Name:ELIAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:626-314-2945
Mailing Address - Street 1:455 N LAKE AVE
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91101-1215
Mailing Address - Country:US
Mailing Address - Phone:626-314-2945
Mailing Address - Fax:626-314-2944
Practice Address - Street 1:455 N LAKE AVE
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91101
Practice Address - Country:US
Practice Address - Phone:626-314-2945
Practice Address - Fax:626-314-2944
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-08
Last Update Date:2019-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHY56896OtherSTATE LICENSE PERMIT
CA1255342747Medicaid