Provider Demographics
NPI:1194534073
Name:DIMETRIOS, MINA (PHARMD)
Entity type:Individual
Prefix:DR
First Name:MINA
Middle Name:
Last Name:DIMETRIOS
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1717 SCOTT RD APT K
Mailing Address - Street 2:
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91504-3875
Mailing Address - Country:US
Mailing Address - Phone:818-815-7772
Mailing Address - Fax:
Practice Address - Street 1:4744 LANKERSHIM BLVD
Practice Address - Street 2:
Practice Address - City:NORTH HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:91602-1833
Practice Address - Country:US
Practice Address - Phone:818-505-0484
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-06
Last Update Date:2025-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA90640183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist