Provider Demographics
NPI:1508440769
Name:GONZALES, CAROLYN J
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:J
Last Name:GONZALES
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 1:210 E SONTERRA BLVD APT 1420
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78258-3961
Mailing Address - Country:US
Mailing Address - Phone:210-810-4202
Mailing Address - Fax:
Practice Address - Street 1:2530 MARSHALL RD
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78259-1608
Practice Address - Country:US
Practice Address - Phone:210-810-4202
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-12
Last Update Date:2021-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX227748183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician