Provider Demographics
NPI:1720626252
Name:MA, MIN MIN (PHARMD)
Entity type:Individual
Prefix:MS
First Name:MIN
Middle Name:MIN
Last Name:MA
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:MS
Other - First Name:AUDREY
Other - Middle Name:
Other - Last Name:MA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1101 MARKET ST
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94103-1513
Mailing Address - Country:US
Mailing Address - Phone:415-558-1538
Mailing Address - Fax:415-558-1563
Practice Address - Street 1:1101 MARKET ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94103-1513
Practice Address - Country:US
Practice Address - Phone:415-558-1538
Practice Address - Fax:415-558-1563
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-16
Last Update Date:2019-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA54673183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist