Healthcare Provider Details

I. General information

NPI: 1326046749
Provider Name (Legal Business Name): EZEQUIEL MENDIETA JR. B.S., R.PH., M.P.H.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3317 CASA BONITA DR
CORPUS CHRISTI TX
78411-3307
US

IV. Provider business mailing address

3317 CASA BONITA DR
CORPUS CHRISTI TX
78411-3307
US

V. Phone/Fax

Practice location:
  • Phone: 361-814-5633
  • Fax: 361-814-5633
Mailing address:
  • Phone: 361-814-5633
  • Fax: 361-814-5633

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number21221
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number1169
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: