Provider Demographics
NPI:1114296415
Name:GOSA, MICHELLE
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:GOSA
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 1:2329 S 24TH AVE
Mailing Address - Street 2:
Mailing Address - City:BROADVIEW
Mailing Address - State:IL
Mailing Address - Zip Code:60155-3822
Mailing Address - Country:US
Mailing Address - Phone:708-223-8848
Mailing Address - Fax:
Practice Address - Street 1:2329 S 24TH AVE
Practice Address - Street 2:
Practice Address - City:BROADVIEW
Practice Address - State:IL
Practice Address - Zip Code:60155-3822
Practice Address - Country:US
Practice Address - Phone:708-223-8848
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-16
Last Update Date:2014-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051290167183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist