Provider Demographics
NPI:1497859441
Name:MINIMS APOTHECARY LLC, DBA BANETH'S PHARMACY
Entity Type:Organization
Organization Name:MINIMS APOTHECARY LLC, DBA BANETH'S PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST - IN - CHARGE
Authorized Official - Prefix:MS
Authorized Official - First Name:SAGEDA
Authorized Official - Middle Name:
Authorized Official - Last Name:MAHMOUD-THIRUCOTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:650-326-8400
Mailing Address - Street 1:900 WILLOW RD
Mailing Address - Street 2:
Mailing Address - City:MENLO PARK
Mailing Address - State:CA
Mailing Address - Zip Code:94025-2544
Mailing Address - Country:US
Mailing Address - Phone:650-326-8400
Mailing Address - Fax:650-323-2609
Practice Address - Street 1:900 WILLOW RD
Practice Address - Street 2:
Practice Address - City:MENLO PARK
Practice Address - State:CA
Practice Address - Zip Code:94025-2544
Practice Address - Country:US
Practice Address - Phone:650-326-8400
Practice Address - Fax:650-323-2609
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-12
Last Update Date:2009-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY46536333600000X
3336C0003X
CAPHY483683336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy
No333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
0523123OtherOTHER ID NUMBER-COMMERCIAL NUMBER
CAPHA465360Medicaid
CAPHA465360Medicaid