Provider Demographics
NPI:1598038283
Name:GONZALES, LAURIE (RPH)
Entity Type:Individual
Prefix:MRS
First Name:LAURIE
Middle Name:
Last Name:GONZALES
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1727 SW ODEM MEDO RD
Mailing Address - Street 2:
Mailing Address - City:REDMOND
Mailing Address - State:OR
Mailing Address - Zip Code:97756-9573
Mailing Address - Country:US
Mailing Address - Phone:541-923-7223
Mailing Address - Fax:
Practice Address - Street 1:1727 SW ODEM MEDO RD
Practice Address - Street 2:
Practice Address - City:REDMOND
Practice Address - State:OR
Practice Address - Zip Code:97756-9573
Practice Address - Country:US
Practice Address - Phone:541-923-7223
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-11
Last Update Date:2012-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR8325183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR8325OtherSTATE PHARMACIST LICENSE