Provider Demographics
NPI:1174295646
Name:GONZALEZ, CECILIA ANISSA
Entity Type:Individual
Prefix:
First Name:CECILIA
Middle Name:ANISSA
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 E BUCHANAN ST
Mailing Address - Street 2:
Mailing Address - City:HARLINGEN
Mailing Address - State:TX
Mailing Address - Zip Code:78550-7077
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1801 W LINCOLN ST
Practice Address - Street 2:
Practice Address - City:HARLINGEN
Practice Address - State:TX
Practice Address - Zip Code:78552-5909
Practice Address - Country:US
Practice Address - Phone:956-428-0734
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-01
Last Update Date:2021-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX69361183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist