Healthcare Provider Details

I. General information

NPI: 1407443898
Provider Name (Legal Business Name): JENNA MENDOZA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENNA CARIDDI

II. Dates (important events)

Enumeration Date: 12/31/2020
Last Update Date: 12/31/2020
Certification Date: 12/31/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 DAKOTA AVE N # A
HURON SD
57350-1630
US

IV. Provider business mailing address

601 W 7TH AVE
LENNOX SD
57039-2421
US

V. Phone/Fax

Practice location:
  • Phone: 605-352-9222
  • Fax:
Mailing address:
  • Phone: 605-553-3822
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number6821
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: