Provider Demographics
NPI:1265144687
Name:MEDINA GONZALEZ, FABIOLA R (PHARMD)
Entity type:Individual
Prefix:
First Name:FABIOLA
Middle Name:R
Last Name:MEDINA GONZALEZ
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36 CALLE NEVAREZ APT 16C
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00927-4536
Mailing Address - Country:US
Mailing Address - Phone:787-241-8829
Mailing Address - Fax:
Practice Address - Street 1:1115 AVE 65 INFANTERIA
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00924-3489
Practice Address - Country:US
Practice Address - Phone:787-768-4700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-16
Last Update Date:2023-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR8027183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist