Provider Demographics
NPI:1568510576
Name:GONZALEZ PHARMACY
Entity Type:Organization
Organization Name:GONZALEZ PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PIC
Authorized Official - Prefix:
Authorized Official - First Name:GABRIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:KAISHAR
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:626-221-2103
Mailing Address - Street 1:1240 N HACIENDA BLVD
Mailing Address - Street 2:STE 105
Mailing Address - City:LA PUENTE
Mailing Address - State:CA
Mailing Address - Zip Code:91744-1662
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1240 N HACIENDA BLVD
Practice Address - Street 2:STE 105
Practice Address - City:LA PUENTE
Practice Address - State:CA
Practice Address - Zip Code:91744-1662
Practice Address - Country:US
Practice Address - Phone:626-221-2103
Practice Address - Fax:626-918-4500
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY482133336L0003X
3336M0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Not Answered3336M0003XSuppliersPharmacyManaged Care Organization Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
5625061OtherOTHER ID NUMBER-COMMERCIAL NUMBER