Provider Demographics
NPI:1518289867
Name:GOMEZ, CARMEN L
Entity Type:Individual
Prefix:MRS
First Name:CARMEN
Middle Name:L
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 1:12028 CHESTER CREEK RD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32218-3323
Mailing Address - Country:US
Mailing Address - Phone:904-619-4110
Mailing Address - Fax:
Practice Address - Street 1:703 CHAFFEE RD S
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32221-1105
Practice Address - Country:US
Practice Address - Phone:904-693-6406
Practice Address - Fax:904-693-4548
Is Sole Proprietor?:No
Enumeration Date:2010-02-26
Last Update Date:2010-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS45939183500000X
PR4269183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist