Provider Demographics
NPI:1619561818
Name:MARTINEZ, GUSTAVO (RPH)
Entity Type:Individual
Prefix:
First Name:GUSTAVO
Middle Name:
Last Name:MARTINEZ
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2367 VINEYARD ST
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-3570
Mailing Address - Country:US
Mailing Address - Phone:209-550-1889
Mailing Address - Fax:
Practice Address - Street 1:2295 S VINEYARD AVE BLDG D
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91761-7925
Practice Address - Country:US
Practice Address - Phone:909-724-3120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-27
Last Update Date:2021-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA84088183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist