Provider Demographics
NPI:1235721804
Name:GONZALEZ RIVERA, JOSE MANUEL (PHARMD)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:MANUEL
Last Name:GONZALEZ RIVERA
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4315 46TH ST APT F10
Mailing Address - Street 2:
Mailing Address - City:SUNNYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11104-2015
Mailing Address - Country:US
Mailing Address - Phone:939-275-1781
Mailing Address - Fax:
Practice Address - Street 1:4315 46TH ST APT F10
Practice Address - Street 2:
Practice Address - City:SUNNYSIDE
Practice Address - State:NY
Practice Address - Zip Code:11104-2015
Practice Address - Country:US
Practice Address - Phone:939-275-1781
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-05
Last Update Date:2021-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY067505183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0000Medicaid