Provider Demographics
NPI:1780138297
Name:MINA, PETER S
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:S
Last Name:MINA
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 1:1401 RHODE ISLAND AVE NE
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20018-3708
Mailing Address - Country:US
Mailing Address - Phone:202-636-3648
Mailing Address - Fax:
Practice Address - Street 1:1401 RHODE ISLAND AVE NE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20018-3708
Practice Address - Country:US
Practice Address - Phone:202-636-3648
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-12
Last Update Date:2016-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCPH100002282183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist