Provider Demographics
NPI:1750828612
Name:GONZALEZ, MADELINE (TECHNICIAN PHARMACIS)
Entity Type:Individual
Prefix:
First Name:MADELINE
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:TECHNICIAN PHARMACIS
Other - Prefix:
Other - First Name:MADELINE
Other - Middle Name:
Other - Last Name:GONZALEZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:TECHNICIAN PHARMACIS
Mailing Address - Street 1:HC 6 BOX 68059
Mailing Address - Street 2:
Mailing Address - City:AGUADILLA
Mailing Address - State:PR
Mailing Address - Zip Code:00603-9898
Mailing Address - Country:US
Mailing Address - Phone:787-219-4473
Mailing Address - Fax:
Practice Address - Street 1:CARR 462 KM 1.2
Practice Address - Street 2:CAIMITAL ALTO
Practice Address - City:AGUADILLA
Practice Address - State:PR
Practice Address - Zip Code:00603
Practice Address - Country:US
Practice Address - Phone:787-219-4473
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-30
Last Update Date:2017-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR5762183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR4065933OtherDRIVER LIC
PR5762OtherPHARMACYST TECHNICIN #