Provider Demographics
NPI:1578230983
Name:GONZALEZ, SANDRA O
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:O
Last Name:GONZALEZ
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 1:598 E HWY US 290
Mailing Address - Street 2:
Mailing Address - City:DRIPPING SPRINGS
Mailing Address - State:TX
Mailing Address - Zip Code:78620-3130
Mailing Address - Country:US
Mailing Address - Phone:512-858-0314
Mailing Address - Fax:
Practice Address - Street 1:598 E HWY US 290
Practice Address - Street 2:
Practice Address - City:DRIPPING SPRINGS
Practice Address - State:TX
Practice Address - Zip Code:78620-3130
Practice Address - Country:US
Practice Address - Phone:512-858-0314
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-24
Last Update Date:2021-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX190100877339607183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician