Provider Demographics
NPI:1194321232
Name:MENDOZA, LORRAINE
Entity type:Individual
Prefix:
First Name:LORRAINE
Middle Name:
Last Name:MENDOZA
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 1:1400 TASKER RD
Mailing Address - Street 2:
Mailing Address - City:STEPHENS CITY
Mailing Address - State:VA
Mailing Address - Zip Code:22655-4047
Mailing Address - Country:US
Mailing Address - Phone:540-868-2217
Mailing Address - Fax:
Practice Address - Street 1:1400 TASKER RD
Practice Address - Street 2:
Practice Address - City:STEPHENS CITY
Practice Address - State:VA
Practice Address - Zip Code:22655-4047
Practice Address - Country:US
Practice Address - Phone:540-868-2217
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-04
Last Update Date:2020-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202214369183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist