Provider Demographics
NPI:1164708715
Name:GONZALEZ, WANDA C (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:WANDA
Middle Name:C
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11332 E 31ST ST
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74146-1905
Mailing Address - Country:US
Mailing Address - Phone:918-622-9684
Mailing Address - Fax:
Practice Address - Street 1:11332 E 31ST ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74146-1905
Practice Address - Country:US
Practice Address - Phone:918-622-9684
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-27
Last Update Date:2011-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK15052183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist