Provider Demographics
NPI:1891970372
Name:GONZALEZ, NILDA (RPH)
Entity Type:Individual
Prefix:
First Name:NILDA
Middle Name:
Last Name:GONZALEZ
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 1:9108 157TH AVE
Mailing Address - Street 2:
Mailing Address - City:HOWARD BEACH
Mailing Address - State:NY
Mailing Address - Zip Code:11414-2740
Mailing Address - Country:US
Mailing Address - Phone:718-529-3928
Mailing Address - Fax:718-845-3758
Practice Address - Street 1:1242 LIBERTY AVE
Practice Address - Street 2:RITEAID # 1921
Practice Address - City:OZONE PARK
Practice Address - State:NY
Practice Address - Zip Code:11417-1044
Practice Address - Country:US
Practice Address - Phone:718-235-7040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-03
Last Update Date:2008-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY041865183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01083669Medicaid