Provider Demographics
NPI:1184174732
Name:MEHTA, MALA
Entity type:Individual
Prefix:
First Name:MALA
Middle Name:
Last Name:MEHTA
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 1:12677 HESPERIA RD
Mailing Address - Street 2:SUITE 180
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92395-7735
Mailing Address - Country:US
Mailing Address - Phone:760-962-1200
Mailing Address - Fax:760-962-1222
Practice Address - Street 1:12677 HESPERIA RD
Practice Address - Street 2:SUITE 180
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395-7735
Practice Address - Country:US
Practice Address - Phone:760-962-1200
Practice Address - Fax:760-962-1222
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-06
Last Update Date:2016-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA46661183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist