Provider Demographics
NPI:1568193035
Name:MINA PHARMACY LLC
Entity Type:Organization
Organization Name:MINA PHARMACY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO-FOUNDER
Authorized Official - Prefix:
Authorized Official - First Name:BRENDALIS
Authorized Official - Middle Name:
Authorized Official - Last Name:ANTIGUA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:929-207-4142
Mailing Address - Street 1:1768 E 172ND ST # 6
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10472-2207
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1768 E 172ND ST # 6
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10472-2207
Practice Address - Country:US
Practice Address - Phone:929-207-4142
Practice Address - Fax:718-255-1046
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-06-23
Last Update Date:2022-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy