Provider Demographics
NPI:1407443898
Name:MENDOZA, JENNA
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:
Last Name:MENDOZA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JENNA
Other - Middle Name:
Other - Last Name:CARIDDI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:601 W 7TH AVE
Mailing Address - Street 2:
Mailing Address - City:LENNOX
Mailing Address - State:SD
Mailing Address - Zip Code:57039-2421
Mailing Address - Country:US
Mailing Address - Phone:605-553-3822
Mailing Address - Fax:
Practice Address - Street 1:100 DAKOTA AVE N # A
Practice Address - Street 2:
Practice Address - City:HURON
Practice Address - State:SD
Practice Address - Zip Code:57350-1630
Practice Address - Country:US
Practice Address - Phone:605-352-9222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-31
Last Update Date:2020-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD6821183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist