Provider Demographics
NPI:1245377993
Name:GONZALEZ, LISSY I
Entity type:Individual
Prefix:
First Name:LISSY
Middle Name:I
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LISSY
Other - Middle Name:I
Other - Last Name:GONZALEZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:HC 57 BOX 11941
Mailing Address - Street 2:
Mailing Address - City:AGUADA
Mailing Address - State:PR
Mailing Address - Zip Code:00602-9857
Mailing Address - Country:US
Mailing Address - Phone:787-868-3512
Mailing Address - Fax:
Practice Address - Street 1:33 CALLE MUNOZ RIVERA W
Practice Address - Street 2:
Practice Address - City:RINCON
Practice Address - State:PR
Practice Address - Zip Code:00677-2124
Practice Address - Country:US
Practice Address - Phone:787-823-2540
Practice Address - Fax:787-823-3183
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR4132183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist