Healthcare Provider Details

I. General information

NPI: 1356574958
Provider Name (Legal Business Name): BENNIE F GONZALES RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/29/2009
Last Update Date: 08/29/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9500 GOLF COURSE RD NW
ALBUQUERQUE NM
87114-4270
US

IV. Provider business mailing address

9500 GOLF COURSE RD NW
ALBUQUERQUE NM
87114-4270
US

V. Phone/Fax

Practice location:
  • Phone: 505-897-7733
  • Fax: 505-897-3533
Mailing address:
  • Phone: 505-897-7733
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRPH4148
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: