Provider Demographics
NPI:1962515767
Name:GOMES ENTERPRISES
Entity type:Organization
Organization Name:GOMES ENTERPRISES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHANTELL
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:PETRALIA
Authorized Official - Suffix:
Authorized Official - Credentials:OWNER
Authorized Official - Phone:888-852-9373
Mailing Address - Street 1:3101 SUNSET BLVD STE 2A
Mailing Address - Street 2:
Mailing Address - City:ROCKLIN
Mailing Address - State:CA
Mailing Address - Zip Code:95677-3097
Mailing Address - Country:US
Mailing Address - Phone:916-624-0570
Mailing Address - Fax:916-624-0591
Practice Address - Street 1:3101 SUNSET BLVD STE 2A
Practice Address - Street 2:
Practice Address - City:ROCKLIN
Practice Address - State:CA
Practice Address - Zip Code:95677-3097
Practice Address - Country:US
Practice Address - Phone:916-624-0570
Practice Address - Fax:916-624-0591
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-16
Last Update Date:2008-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY44817183500000X, 333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
No333600000XSuppliersPharmacyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA448170Medicaid
0519073OtherNABP