Provider Demographics
NPI:1104526979
Name:GONZALEZ, AIDA ANGELICA
Entity type:Individual
Prefix:
First Name:AIDA
Middle Name:ANGELICA
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 1:24991 ALESSANDRO BLVD
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92553-5708
Mailing Address - Country:US
Mailing Address - Phone:951-485-4450
Mailing Address - Fax:951-485-4920
Practice Address - Street 1:24991 ALESSANDRO BLVD
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92553-5708
Practice Address - Country:US
Practice Address - Phone:951-485-4450
Practice Address - Fax:951-485-4920
Is Sole Proprietor?:No
Enumeration Date:2023-03-09
Last Update Date:2023-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CATCH46708183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician