Active NPI
Vidal Mateo Mendoza III
- Pharmacist
- Polacca, AZ
National Provider Identifier
1891524740
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Pharmacist
- License
- 2961463
- Practice address
- Highway 264 Mile Post 388
Polacca, AZ 86042 - Phone
- (928) 737-6000
- NPI assigned
- Jul 30, 2024
- Last updated
- Jul 30, 2024
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Pharmacist | 183500000X | 2961463 | ID | Primary |
Addresses
Primary practice location
Highway 264 Mile Post 388
Polacca, AZ 86042
Mailing address
PO Box 1081
Keams Canyon, AZ 86034-1081
Phone (210) 803-4703
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 2961463 | ID | MD | Pharmacist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1722297600000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1722297600000",
"number": "1891524740",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "PO BOX 1081",
"city": "KEAMS CANYON",
"state": "AZ",
"postal_code": "860341081",
"telephone_number": "210-803-4703"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "HIGHWAY 264 MILE POST 388",
"city": "POLACCA",
"state": "AZ",
"postal_code": "86042",
"telephone_number": "928-737-6000"
}
],
"practiceLocations": [],
"basic": {
"last_name": "MENDOZA",
"first_name": "VIDAL",
"middle_name": "MATEO",
"name_suffix": "III",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2024-07-30",
"last_updated": "2024-07-30",
"certification_date": "2021-01-20",
"status": "A"
},
"taxonomies": [
{
"code": "183500000X",
"taxonomy_group": "",
"desc": "Pharmacist",
"state": "ID",
"license": "2961463",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Polacca, AZ
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 30, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.