Provider Demographics
NPI:1699056267
Name:GONZALES, MARIETTA BOQUIRON (RPH)
Entity type:Individual
Prefix:
First Name:MARIETTA
Middle Name:BOQUIRON
Last Name:GONZALES
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2647 SPRINGS RD
Mailing Address - Street 2:
Mailing Address - City:VALLEJO
Mailing Address - State:CA
Mailing Address - Zip Code:94591-5712
Mailing Address - Country:US
Mailing Address - Phone:707-557-5974
Mailing Address - Fax:707-557-2837
Practice Address - Street 1:2647 SPRINGS RD
Practice Address - Street 2:
Practice Address - City:VALLEJO
Practice Address - State:CA
Practice Address - Zip Code:94591-5712
Practice Address - Country:US
Practice Address - Phone:707-557-5974
Practice Address - Fax:707-557-2837
Is Sole Proprietor?:No
Enumeration Date:2011-09-08
Last Update Date:2011-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPH46138183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist