Provider Demographics
NPI:1275703159
Name:GOMEZ, BRENDA I
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:I
Last Name:GOMEZ
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:CC14 CALLE 29
Mailing Address - Street 2:URB RIO GRANDE STATE
Mailing Address - City:RIO GRANDE
Mailing Address - State:PR
Mailing Address - Zip Code:00745-5073
Mailing Address - Country:US
Mailing Address - Phone:787-206-0102
Mailing Address - Fax:
Practice Address - Street 1:COND GOLDEN TOWER # C8
Practice Address - Street 2:AVE. PONTEZUELA
Practice Address - City:CAROLINA
Practice Address - State:PR
Practice Address - Zip Code:00983-1899
Practice Address - Country:US
Practice Address - Phone:787-752-9955
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-06
Last Update Date:2008-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR2120183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician