Provider Demographics
NPI:1326046749
Name:MENDIETA, EZEQUIEL JR (BS, RPH, MPH)
Entity Type:Individual
Prefix:MR
First Name:EZEQUIEL
Middle Name:
Last Name:MENDIETA
Suffix:JR
Gender:M
Credentials:BS, RPH, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3317 CASA BONITA DR
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78411-3307
Mailing Address - Country:US
Mailing Address - Phone:361-814-5633
Mailing Address - Fax:361-814-5633
Practice Address - Street 1:3317 CASA BONITA DR
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78411-3307
Practice Address - Country:US
Practice Address - Phone:361-814-5633
Practice Address - Fax:361-814-5633
Is Sole Proprietor?:No
Enumeration Date:2005-07-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX21221183500000X
AK1169183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist