Provider Demographics
NPI:1083948806
Name:GOMEZ, NATHANIEL DAVID (PHARM D)
Entity Type:Individual
Prefix:DR
First Name:NATHANIEL
Middle Name:DAVID
Last Name:GOMEZ
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:155 COMMERCE DR
Mailing Address - Street 2:
Mailing Address - City:GREEN RIVER
Mailing Address - State:WY
Mailing Address - Zip Code:82935-6179
Mailing Address - Country:US
Mailing Address - Phone:307-871-7054
Mailing Address - Fax:307-875-0166
Practice Address - Street 1:905 BRIDGER DR
Practice Address - Street 2:
Practice Address - City:GREEN RIVER
Practice Address - State:WY
Practice Address - Zip Code:82935-5879
Practice Address - Country:US
Practice Address - Phone:307-875-7841
Practice Address - Fax:307-875-0166
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-25
Last Update Date:2009-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY3157183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist