Provider Demographics
NPI:1942780770
Name:GONZALEZ, MADELINE
Entity Type:Individual
Prefix:
First Name:MADELINE
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:HC 57 BOX 10740
Mailing Address - Street 2:
Mailing Address - City:AGUADA
Mailing Address - State:PR
Mailing Address - Zip Code:00602-9850
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:CVS PHARMACY
Practice Address - Street 2:374 AVE PONCE DE LEON
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00918
Practice Address - Country:US
Practice Address - Phone:787-560-5773
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-21
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR006538183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR006538OtherCOLEGIO DE FARMACUTICOS DE PUERTO RICO