Provider Demographics
NPI:1275670697
Name:GONZALEZ, MYRNA
Entity Type:Individual
Prefix:
First Name:MYRNA
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:PO BOX 2993
Mailing Address - Street 2:
Mailing Address - City:GUAYAMA
Mailing Address - State:PR
Mailing Address - Zip Code:00785-2993
Mailing Address - Country:US
Mailing Address - Phone:787-864-5880
Mailing Address - Fax:787-864-8541
Practice Address - Street 1:89 CALLE CALIMANO N
Practice Address - Street 2:
Practice Address - City:GUAYAMA
Practice Address - State:PR
Practice Address - Zip Code:00784-4420
Practice Address - Country:US
Practice Address - Phone:787-864-5880
Practice Address - Fax:787-864-8541
Is Sole Proprietor?:No
Enumeration Date:2007-02-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR2283183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist