Provider Demographics
NPI:1144695172
Name:GOMEZ, NIDIA
Entity type:Individual
Prefix:
First Name:NIDIA
Middle Name:
Last Name: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 1:56 AZALEA
Mailing Address - Street 2:EST SANTA BARBARA
Mailing Address - City:GURABO
Mailing Address - State:PR
Mailing Address - Zip Code:00778
Mailing Address - Country:US
Mailing Address - Phone:787-469-3267
Mailing Address - Fax:787-746-1086
Practice Address - Street 1:56 AZALEA
Practice Address - Street 2:EST SANTA BARBARA
Practice Address - City:GURABO
Practice Address - State:PR
Practice Address - Zip Code:00778
Practice Address - Country:US
Practice Address - Phone:787-469-3267
Practice Address - Fax:787-746-1086
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-02
Last Update Date:2015-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR4153183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR66364OtherPHAMACISTS REGISTRATION
PR4153OtherPHARMACIST LICENSE