Provider Demographics
NPI:1558725168
Name:GONPO, TASHI
Entity Type:Individual
Prefix:
First Name:TASHI
Middle Name:
Last Name:GONPO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 FOREST PARK
Mailing Address - Street 2:
Mailing Address - City:HERCULES
Mailing Address - State:CA
Mailing Address - Zip Code:94547-3904
Mailing Address - Country:US
Mailing Address - Phone:310-666-7465
Mailing Address - Fax:
Practice Address - Street 1:1500 NORTHGATE DR
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94903-3671
Practice Address - Country:US
Practice Address - Phone:415-492-0888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-09
Last Update Date:2016-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA74360183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist