Provider Demographics
NPI:1619341302
Name:HANNA, MINA
Entity Type:Individual
Prefix:
First Name:MINA
Middle Name:
Last Name:HANNA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1914 ALEXANDER SPRINGS LN APT 18
Mailing Address - Street 2:
Mailing Address - City:WAKE FOREST
Mailing Address - State:NC
Mailing Address - Zip Code:27587-4030
Mailing Address - Country:US
Mailing Address - Phone:919-590-2152
Mailing Address - Fax:
Practice Address - Street 1:2624 SUNSET AVE
Practice Address - Street 2:
Practice Address - City:ROCKY MOUNT
Practice Address - State:NC
Practice Address - Zip Code:27804-3747
Practice Address - Country:US
Practice Address - Phone:252-937-4999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-18
Last Update Date:2015-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC25536183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist