Healthcare Provider Details

I. General information

NPI: 1013615616
Provider Name (Legal Business Name): ROSA MARIA MENDEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/22/2023
Last Update Date: 02/22/2023
Certification Date: 02/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4005 HAVERFORD AVE
RIVERSIDE CA
92507-4817
US

IV. Provider business mailing address

4920 LA SIERRA AVE
RIVERSIDE CA
92505-2612
US

V. Phone/Fax

Practice location:
  • Phone: 909-968-3291
  • Fax:
Mailing address:
  • Phone: 951-688-4196
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number165050
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: