Provider Demographics
NPI:1245852045
Name:SIDHOM, MINA
Entity type:Individual
Prefix:DR
First Name:MINA
Middle Name:
Last Name:SIDHOM
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 1:101 NEW BRUNSWICK AVE
Mailing Address - Street 2:
Mailing Address - City:HOPELAWN
Mailing Address - State:NJ
Mailing Address - Zip Code:08861-2361
Mailing Address - Country:US
Mailing Address - Phone:732-934-6134
Mailing Address - Fax:732-934-6135
Practice Address - Street 1:101 NEW BRUNSWICK AVE
Practice Address - Street 2:
Practice Address - City:HOPELAWN
Practice Address - State:NJ
Practice Address - Zip Code:08861-2361
Practice Address - Country:US
Practice Address - Phone:732-934-6134
Practice Address - Fax:732-934-6135
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-14
Last Update Date:2020-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI03617200183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist