Provider Demographics
NPI:1922366079
Name:MINA PHARMACY LTC LLC
Entity Type:Organization
Organization Name:MINA PHARMACY LTC LLC
Other - Org Name:MINA PHARMACY #14
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF PHARMACY
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:
Authorized Official - Last Name:MOSER
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 1:275 W KAAHUMANU AVE STE 1C01A
Practice Address - Street 2:
Practice Address - City:KAHULUI
Practice Address - State:HI
Practice Address - Zip Code:96732-1629
Practice Address - Country:US
Practice Address - Phone:808-856-8030
Practice Address - Fax:808-442-9634
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-26
Last Update Date:2012-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIPHY-8123336I0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336I0012XSuppliersPharmacyInstitutional Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1240833OtherNCPDP PROVIDER IDENTIFICATION NUMBER