Provider Demographics
NPI:1154928836
Name:MOUSSA, MINA SAMY
Entity type:Individual
Prefix:
First Name:MINA
Middle Name:SAMY
Last Name:MOUSSA
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 1:12540 MCCANN DR
Mailing Address - Street 2:
Mailing Address - City:SANTA FE SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:90670-3337
Mailing Address - Country:US
Mailing Address - Phone:424-205-0150
Mailing Address - Fax:
Practice Address - Street 1:12540 MCCANN DR
Practice Address - Street 2:
Practice Address - City:SANTA FE SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:90670-3337
Practice Address - Country:US
Practice Address - Phone:424-205-0150
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-06
Last Update Date:2020-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA83493183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist