Provider Demographics
NPI:1609269356
Name:MENDOZA, WANDA E SR
Entity Type:Individual
Prefix:
First Name:WANDA
Middle Name:E
Last Name:MENDOZA
Suffix:SR
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:PO BOX 1052
Mailing Address - Street 2:BOX 1052
Mailing Address - City:CAMUY
Mailing Address - State:PR
Mailing Address - Zip Code:00627-1052
Mailing Address - Country:US
Mailing Address - Phone:787-396-0010
Mailing Address - Fax:
Practice Address - Street 1:#669 PENA
Practice Address - Street 2:BO PENTE BOX 1052
Practice Address - City:CAMY
Practice Address - State:PR
Practice Address - Zip Code:00627-0062
Practice Address - Country:US
Practice Address - Phone:787-396-0010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-05
Last Update Date:2015-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR8195183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician