Provider Demographics
NPI:1275894594
Name:MINA CORPORATION
Entity Type:Organization
Organization Name:MINA CORPORATION
Other - Org Name:MINA PHARMACY #17
Other - Org Type:Doing Business As
Authorized Official - Title/Position: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:808-738-4540
Mailing Address - Street 1:3375 KOAPAKA ST STE F245
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96819-1881
Mailing Address - Country:US
Mailing Address - Phone:808-738-4540
Mailing Address - Fax:808-690-9174
Practice Address - Street 1:440 KILANI AVE
Practice Address - Street 2:
Practice Address - City:WAHIAWA
Practice Address - State:HI
Practice Address - Zip Code:96786-1837
Practice Address - Country:US
Practice Address - Phone:808-533-9020
Practice Address - Fax:808-690-9189
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-04
Last Update Date:2015-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIPHY8143336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI1266830007Medicare NSC
2134692OtherPK