Provider Demographics
NPI:1891524740
Name:MENDOZA, VIDAL MATEO III
Entity type:Individual
Prefix:
First Name:VIDAL
Middle Name:MATEO
Last Name:MENDOZA
Suffix:III
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:PO BOX 1081
Mailing Address - Street 2:
Mailing Address - City:KEAMS CANYON
Mailing Address - State:AZ
Mailing Address - Zip Code:86034-1081
Mailing Address - Country:US
Mailing Address - Phone:210-803-4703
Mailing Address - Fax:
Practice Address - Street 1:HIGHWAY 264 MILE POST 388
Practice Address - Street 2:
Practice Address - City:POLACCA
Practice Address - State:AZ
Practice Address - Zip Code:86042
Practice Address - Country:US
Practice Address - Phone:928-737-6000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-30
Last Update Date:2024-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID2961463183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist