Provider Demographics
NPI:1144729955
Name:VERGARA, INA MARIE ANGELA MENDOZA
Entity type:Individual
Prefix:
First Name:INA MARIE ANGELA
Middle Name:MENDOZA
Last Name:VERGARA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2336 N COAST HWY
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:OR
Mailing Address - Zip Code:97365-1799
Mailing Address - Country:US
Mailing Address - Phone:541-265-8596
Mailing Address - Fax:
Practice Address - Street 1:2336 N COAST HWY
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:OR
Practice Address - Zip Code:97365-1799
Practice Address - Country:US
Practice Address - Phone:541-265-8596
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-07
Last Update Date:2018-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR00163663336C0003X, 1835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist