Provider Demographics
NPI:1013063254
Name:GONZALO, JILL MARIE (BSPH)
Entity Type:Individual
Prefix:MS
First Name:JILL
Middle Name:MARIE
Last Name:GONZALO
Suffix:
Gender:F
Credentials:BSPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 MOIR AVE
Mailing Address - Street 2:
Mailing Address - City:WEST CONSHOHOCKEN
Mailing Address - State:PA
Mailing Address - Zip Code:19428-2843
Mailing Address - Country:US
Mailing Address - Phone:610-828-4120
Mailing Address - Fax:610-828-4120
Practice Address - Street 1:200 W RIDGE PIKE
Practice Address - Street 2:200 RIDGE PIKE
Practice Address - City:CONSHOHOCKEN
Practice Address - State:PA
Practice Address - Zip Code:19428-3702
Practice Address - Country:US
Practice Address - Phone:610-276-1000
Practice Address - Fax:610-276-1004
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP-095368L183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PARP-095368LOtherPHARMACY LICENSE