Provider Demographics
NPI:1164199733
Name:GONZALES, JOUSTON TAYLOR
Entity Type:Individual
Prefix:
First Name:JOUSTON
Middle Name:TAYLOR
Last Name:GONZALES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:474 1ST ST
Mailing Address - Street 2:
Mailing Address - City:LINDSAY
Mailing Address - State:CA
Mailing Address - Zip Code:93247-2104
Mailing Address - Country:US
Mailing Address - Phone:559-667-1040
Mailing Address - Fax:559-592-6538
Practice Address - Street 1:1051 W VISALIA RD
Practice Address - Street 2:
Practice Address - City:EXETER
Practice Address - State:CA
Practice Address - Zip Code:93221-2202
Practice Address - Country:US
Practice Address - Phone:559-592-4901
Practice Address - Fax:559-592-6538
Is Sole Proprietor?:No
Enumeration Date:2021-08-23
Last Update Date:2021-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA138349183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician