Healthcare Provider Details

I. General information

NPI: 1700702354
Provider Name (Legal Business Name): MARCELO R GONZALEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2026
Last Update Date: 06/27/2026
Certification Date: 06/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2427 W CHICAGO AVE
CHICAGO IL
60622-4631
US

IV. Provider business mailing address

508 N FOX TRL
ROUND LAKE IL
60073-2355
US

V. Phone/Fax

Practice location:
  • Phone: 773-342-6060
  • Fax:
Mailing address:
  • Phone: 224-538-0457
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number051.308702
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: