Provider Demographics
NPI:1235734211
Name:GONZALEZ MEDINA, DONNY SR
Entity Type:Individual
Prefix:MR
First Name:DONNY
Middle Name:
Last Name:GONZALEZ MEDINA
Suffix:SR
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 1:4760 NW 178TH TER
Mailing Address - Street 2:
Mailing Address - City:MIAMI GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33055-3232
Mailing Address - Country:US
Mailing Address - Phone:305-450-4543
Mailing Address - Fax:
Practice Address - Street 1:802 E 25TH ST
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33013-3402
Practice Address - Country:US
Practice Address - Phone:305-450-4543
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-30
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS56940183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist