Provider Demographics
NPI:1093405359
Name:GONZALO, SAMANTHA ERICKA CARMONA (RPH)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:ERICKA CARMONA
Last Name:GONZALO
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4014 PLAZA GOLDORADO CIR
Mailing Address - Street 2:
Mailing Address - City:CAMERON PARK
Mailing Address - State:CA
Mailing Address - Zip Code:95682-8257
Mailing Address - Country:US
Mailing Address - Phone:530-676-2095
Mailing Address - Fax:
Practice Address - Street 1:4014 PLAZA GOLDORADO CIR
Practice Address - Street 2:
Practice Address - City:CAMERON PARK
Practice Address - State:CA
Practice Address - Zip Code:95682-8257
Practice Address - Country:US
Practice Address - Phone:530-676-2095
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-10
Last Update Date:2023-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA87849183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist