Provider Demographics
NPI:1285803122
Name:DE GOMEZ, WANDA A
Entity type:Individual
Prefix:MRS
First Name:WANDA
Middle Name:A
Last Name:DE GOMEZ
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:GARDENIA ST H27 CONDADO VIEJO
Mailing Address - Street 2:
Mailing Address - City:CAGUAS
Mailing Address - State:PR
Mailing Address - Zip Code:00725
Mailing Address - Country:US
Mailing Address - Phone:787-743-8072
Mailing Address - Fax:
Practice Address - Street 1:CALLE GARDENIA H27 CONDADO VIEJO
Practice Address - Street 2:
Practice Address - City:CAGUAS
Practice Address - State:PR
Practice Address - Zip Code:00725
Practice Address - Country:US
Practice Address - Phone:787-746-1525
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-25
Last Update Date:2008-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1735183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist