Provider Demographics
NPI:1275709834
Name:MINA PHARMACY LTC, LLC
Entity Type:Organization
Organization Name:MINA PHARMACY LTC, LLC
Other - Org Name:MINA PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ADEL
Authorized Official - Middle Name:
Authorized Official - Last Name:ETINAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:808-738-4540
Mailing Address - Street 1:3375 KOAPAKA STREET
Mailing Address - Street 2:SUITE F245
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96819-1816
Mailing Address - Country:US
Mailing Address - Phone:808-738-4540
Mailing Address - Fax:808-690-9174
Practice Address - Street 1:1251 KILAUEA AVE
Practice Address - Street 2:#190C
Practice Address - City:HILO
Practice Address - State:HI
Practice Address - Zip Code:96720-8509
Practice Address - Country:US
Practice Address - Phone:808-935-3100
Practice Address - Fax:808-935-6800
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-05
Last Update Date:2015-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIPHY7063336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI5851110004Medicare NSC
HI1275709834OtherNPI
HI5851110004OtherPTAN
HI618077Medicaid