Provider Demographics
NPI:1730439779
Name:MARI-MINA PHARMACEUTICALS INC
Entity type:Organization
Organization Name:MARI-MINA PHARMACEUTICALS INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PIC
Authorized Official - Prefix:
Authorized Official - First Name:NOHA
Authorized Official - Middle Name:
Authorized Official - Last Name:KOLTA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-477-6300
Mailing Address - Street 1:10374 TRADEMARK ST
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-5824
Mailing Address - Country:US
Mailing Address - Phone:909-477-6300
Mailing Address - Fax:909-477-3009
Practice Address - Street 1:10374 TRADEMARK ST
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-5824
Practice Address - Country:US
Practice Address - Phone:909-477-6300
Practice Address - Fax:909-477-3009
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-18
Last Update Date:2016-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336H0001X, 3336C0004X, 3336C0003X, 332B00000X, 333600000X
CA509353336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2136926OtherPK
6420480002Medicare NSC