Provider Demographics
NPI:1679665012
Name:GOMEZ MARTINEZ, LIANCY AMANDA (PHARMD, BCPS, BCGP)
Entity Type:Individual
Prefix:DR
First Name:LIANCY
Middle Name:AMANDA
Last Name:GOMEZ MARTINEZ
Suffix:
Gender:F
Credentials:PHARMD, BCPS, BCGP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5000 S 5TH AVE # 119
Mailing Address - Street 2:
Mailing Address - City:HINES
Mailing Address - State:IL
Mailing Address - Zip Code:60141-3030
Mailing Address - Country:US
Mailing Address - Phone:708-202-8387
Mailing Address - Fax:
Practice Address - Street 1:5000 SOUTH FIFTH AVENUE
Practice Address - Street 2:
Practice Address - City:HINES
Practice Address - State:IL
Practice Address - Zip Code:60141
Practice Address - Country:US
Practice Address - Phone:708-202-8387
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2023-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051289775183500000X, 183500000X
IL91018161835G0303X
IL3050066081835P1200X, 1835P1200X
PR5021183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy
No183500000XPharmacy Service ProvidersPharmacist
Yes1835G0303XPharmacy Service ProvidersPharmacistGeriatric