Provider Demographics
NPI:1124622030
Name:LAZO, JOSE GUSTAVO JR
Entity type:Individual
Prefix:
First Name:JOSE
Middle Name:GUSTAVO
Last Name:LAZO
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:521 PARNASSUS AVE ROOM C-152, BOX 0622
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94143
Mailing Address - Country:US
Mailing Address - Phone:973-986-3098
Mailing Address - Fax:
Practice Address - Street 1:521 PARNASSUS AVE ROOM C-152, B- 0622
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94143
Practice Address - Country:US
Practice Address - Phone:973-986-3098
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-23
Last Update Date:2022-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA81272183500000X
NJ28RJ07964333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No333600000XSuppliersPharmacy