Provider Demographics
NPI:1134404866
Name:GONZALES, JOSEPH ANDREW (RPH, BSP)
Entity type:Individual
Prefix:MR
First Name:JOSEPH
Middle Name:ANDREW
Last Name:GONZALES
Suffix:
Gender:M
Credentials:RPH, BSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:723 CROWN RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80904-1729
Mailing Address - Country:US
Mailing Address - Phone:719-471-0646
Mailing Address - Fax:719-471-0646
Practice Address - Street 1:625 N 19TH ST
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80904-3459
Practice Address - Country:US
Practice Address - Phone:719-473-8834
Practice Address - Fax:719-473-0445
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-13
Last Update Date:2011-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPHA-11544183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist