Provider Demographics
NPI:1013299833
Name:GONZALEZ, JOHANNA (RPH)
Entity Type:Individual
Prefix:
First Name:JOHANNA
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 1:35 BURROUGHS DR
Mailing Address - Street 2:
Mailing Address - City:PALM COAST
Mailing Address - State:FL
Mailing Address - Zip Code:32137-9400
Mailing Address - Country:US
Mailing Address - Phone:386-246-4359
Mailing Address - Fax:
Practice Address - Street 1:1109 PALM COAST PKWY SW
Practice Address - Street 2:
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32137-4704
Practice Address - Country:US
Practice Address - Phone:386-445-7041
Practice Address - Fax:386-446-8088
Is Sole Proprietor?:No
Enumeration Date:2011-09-19
Last Update Date:2011-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS 38220183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist