Provider Demographics
NPI:1124419783
Name:EID, MINA
Entity type:Individual
Prefix:
First Name:MINA
Middle Name:
Last Name:EID
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 1:604 FAIRVIEW AVE
Mailing Address - Street 2:1R
Mailing Address - City:RIDGEWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11385-2433
Mailing Address - Country:US
Mailing Address - Phone:347-359-7974
Mailing Address - Fax:
Practice Address - Street 1:604 FAIRVIEW AVE
Practice Address - Street 2:1R
Practice Address - City:RIDGEWOOD
Practice Address - State:NY
Practice Address - Zip Code:11385-2433
Practice Address - Country:US
Practice Address - Phone:347-359-7974
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-17
Last Update Date:2015-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY060083183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist