Healthcare Provider Details

I. General information

NPI: 1962515767
Provider Name (Legal Business Name): GOMES ENTERPRISES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/16/2006
Last Update Date: 07/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3101 SUNSET BLVD STE 2A
ROCKLIN CA
95677-3097
US

IV. Provider business mailing address

3101 SUNSET BLVD STE 2A
ROCKLIN CA
95677-3097
US

V. Phone/Fax

Practice location:
  • Phone: 916-624-0570
  • Fax: 916-624-0591
Mailing address:
  • Phone: 916-624-0570
  • Fax: 916-624-0591

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPHY44817
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License NumberPHY44817
License Number StateCA

VIII. Authorized Official

Name: MRS. CHANTELL LEE PETRALIA
Title or Position: OWNER CEO
Credential: OWNER
Phone: 888-852-9373