Provider Demographics
NPI:1326338898
Name:GOSMA, BERNARD T (RPH)
Entity Type:Individual
Prefix:MR
First Name:BERNARD
Middle Name:T
Last Name:GOSMA
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4823 S HIGHWAY 95
Mailing Address - Street 2:
Mailing Address - City:FORT MOHAVE
Mailing Address - State:AZ
Mailing Address - Zip Code:86426-8314
Mailing Address - Country:US
Mailing Address - Phone:928-704-4443
Mailing Address - Fax:928-704-1684
Practice Address - Street 1:4823 S HIGHWAY 95
Practice Address - Street 2:
Practice Address - City:FORT MOHAVE
Practice Address - State:AZ
Practice Address - Zip Code:86426-8314
Practice Address - Country:US
Practice Address - Phone:928-704-4443
Practice Address - Fax:928-704-1684
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-18
Last Update Date:2011-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS11942183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist