Provider Demographics
NPI:1801290440
Name:ST MINA INC
Entity type:Organization
Organization Name:ST MINA INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PIC/ SECRETERY
Authorized Official - Prefix:
Authorized Official - First Name:NADER
Authorized Official - Middle Name:
Authorized Official - Last Name:ABADIER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-851-0311
Mailing Address - Street 1:7643 CABRILLO WAY
Mailing Address - Street 2:
Mailing Address - City:EASTVALE
Mailing Address - State:CA
Mailing Address - Zip Code:92880-0923
Mailing Address - Country:US
Mailing Address - Phone:951-738-9664
Mailing Address - Fax:909-350-3223
Practice Address - Street 1:16701 VALLEY BLVD STE E
Practice Address - Street 2:
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92335-6696
Practice Address - Country:US
Practice Address - Phone:909-823-2515
Practice Address - Fax:909-823-2514
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-10
Last Update Date:2017-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336L0003X
CAPHY525573336C0003X
CA525573336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2148250OtherPK
CA1801290440Medicaid