Healthcare Provider Details

I. General information

NPI: 1740761055
Provider Name (Legal Business Name): LUIS GONZALEZ RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2018
Last Update Date: 08/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

WALMART PUERTO RICO INC STATE ROAD #3 KM 15.2 BARRIO CANOVANILLAS
CAROLINA PR
00987
US

IV. Provider business mailing address

WALMART PUERTO RICO INC 16300 MONTE REAL PLAZA
CAROLINA PR
00987
US

V. Phone/Fax

Practice location:
  • Phone: 787-653-7777
  • Fax:
Mailing address:
  • Phone: 787-653-7777
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number4105
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: