Healthcare Provider Details

I. General information

NPI: 1750498762
Provider Name (Legal Business Name): JASMINE GONZALVO PHARM. D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2006
Last Update Date: 11/09/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 W 10TH ST
INDIANAPOLIS IN
46202-2859
US

IV. Provider business mailing address

5514 WINTHROP AVE
INDIANAPOLIS IN
46220-3249
US

V. Phone/Fax

Practice location:
  • Phone: 317-613-2315
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number26021703A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: