Provider Demographics
NPI:1700929007
Name:GONZALEZ, MADELINE JR
Entity Type:Individual
Prefix:
First Name:MADELINE
Middle Name:
Last Name:GONZALEZ
Suffix:JR
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MADELINE
Other - Middle Name:
Other - Last Name:GONZALEZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:CARR. 456 KM 5.1 BO CIBAO
Mailing Address - Street 2:HC- 01 BOX 4849
Mailing Address - City:CAMUY
Mailing Address - State:PR
Mailing Address - Zip Code:00627
Mailing Address - Country:US
Mailing Address - Phone:787-262-9194
Mailing Address - Fax:
Practice Address - Street 1:CARR. 456 KM 5.1 BO CIBAO
Practice Address - Street 2:HC- 01 BOX 4849
Practice Address - City:CAMUY
Practice Address - State:PR
Practice Address - Zip Code:00627
Practice Address - Country:US
Practice Address - Phone:787-262-9194
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR3791183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR3791OtherPHARMACIST TECHNICIAN