Provider Demographics
NPI:1558634782
Name:GONZALES, MIKE (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:MIKE
Middle Name:
Last Name:GONZALES
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4236 PARK HILL DR
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79902-1356
Mailing Address - Country:US
Mailing Address - Phone:915-313-3683
Mailing Address - Fax:
Practice Address - Street 1:1720 MURCHISON DR
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79902-2921
Practice Address - Country:US
Practice Address - Phone:915-313-9870
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-19
Last Update Date:2012-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX41616183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist