Provider Demographics
NPI:1780058669
Name:GAMBOA, FELICITAS
Entity type:Individual
Prefix:MRS
First Name:FELICITAS
Middle Name:
Last Name:GAMBOA
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 1:2121 SW 36TH ST
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78237-3360
Mailing Address - Country:US
Mailing Address - Phone:210-358-5141
Mailing Address - Fax:210-702-6900
Practice Address - Street 1:2121 SW 36TH ST
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78237-3360
Practice Address - Country:US
Practice Address - Phone:210-358-5141
Practice Address - Fax:210-702-6900
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-16
Last Update Date:2015-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX28571183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist