Provider Demographics
NPI:1861131211
Name:AVVA MINA INC
Entity type:Organization
Organization Name:AVVA MINA INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RANIA
Authorized Official - Middle Name:
Authorized Official - Last Name:SHENODA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-532-5588
Mailing Address - Street 1:639 N 13TH AVE
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-4906
Mailing Address - Country:US
Mailing Address - Phone:909-532-5588
Mailing Address - Fax:
Practice Address - Street 1:639 N 13TH AVE
Practice Address - Street 2:
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-4906
Practice Address - Country:US
Practice Address - Phone:909-532-5588
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-06-02
Last Update Date:2025-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1861131211Medicaid