Provider Demographics
NPI:1801568902
Name:GONZALEZ, AMARYLIS
Entity type:Individual
Prefix:
First Name:AMARYLIS
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 1:7575 OSCEOLA POLK LINE RD
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:FL
Mailing Address - Zip Code:33896-9112
Mailing Address - Country:US
Mailing Address - Phone:321-677-0531
Mailing Address - Fax:321-677-0537
Practice Address - Street 1:7575 OSCEOLA POLK LINE RD
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:FL
Practice Address - Zip Code:33896-9112
Practice Address - Country:US
Practice Address - Phone:321-677-0531
Practice Address - Fax:321-677-0537
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-28
Last Update Date:2021-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS40902183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAMARIC1122Medicaid