Provider Demographics
NPI:1356941348
Name:GOMEZ, DIEGO (PHARMD)
Entity type:Individual
Prefix:
First Name:DIEGO
Middle Name:
Last Name:GOMEZ
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7836 TIMBERLIN PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-5413
Mailing Address - Country:US
Mailing Address - Phone:941-204-1610
Mailing Address - Fax:
Practice Address - Street 1:11757 BEACH BLVD STE 7
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32246-6633
Practice Address - Country:US
Practice Address - Phone:904-531-4556
Practice Address - Fax:904-376-7718
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-28
Last Update Date:2020-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS49289183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist