Provider Demographics
NPI:1669150447
Name:GONZALES, CIARA JOANNE (PHARMD)
Entity type:Individual
Prefix:
First Name:CIARA
Middle Name:JOANNE
Last Name:GONZALES
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:CIARA
Other - Middle Name:JOANNE
Other - Last Name:WHITE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5245 28TH AVE S APT 105
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58104-9080
Mailing Address - Country:US
Mailing Address - Phone:612-545-6112
Mailing Address - Fax:
Practice Address - Street 1:2101 ELM ST N
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58102-2417
Practice Address - Country:US
Practice Address - Phone:612-545-6112
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-10
Last Update Date:2023-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN126085183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist