Provider Demographics
NPI:1386775591
Name:GONZALES, GEORGE MISAEL (RPH)
Entity type:Individual
Prefix:MR
First Name:GEORGE
Middle Name:MISAEL
Last Name:GONZALES
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 COYOTE RIDGE TRAIL
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87507
Mailing Address - Country:US
Mailing Address - Phone:505-476-8353
Mailing Address - Fax:
Practice Address - Street 1:1301 SILER RD
Practice Address - Street 2:BUILDING A
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87507-3541
Practice Address - Country:US
Practice Address - Phone:505-476-8353
Practice Address - Fax:505-424-3438
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2012-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMNM 4524183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist