Provider Demographics
NPI:1073850707
Name:MINO, CASEY QUINN JOHNSON (PHARMD)
Entity type:Individual
Prefix:
First Name:CASEY
Middle Name:QUINN JOHNSON
Last Name:MINO
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12749 MIDDLE BAY DR
Mailing Address - Street 2:
Mailing Address - City:KODIAK
Mailing Address - State:AK
Mailing Address - Zip Code:99615-9420
Mailing Address - Country:US
Mailing Address - Phone:228-219-9888
Mailing Address - Fax:
Practice Address - Street 1:13034 SHRINERS BLVD STE A
Practice Address - Street 2:
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39532-8250
Practice Address - Country:US
Practice Address - Phone:228-392-5355
Practice Address - Fax:228-392-1620
Is Sole Proprietor?:No
Enumeration Date:2013-01-15
Last Update Date:2019-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK1890183500000X
MSE-010588183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist