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General NPI Number Information
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NPI Number | 1619561818
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Entity Type | Individual
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Provider Name | GUSTAVO MARTINEZ RPH
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Gender | Male
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Dates
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Enumeration Date | 02/27/2021
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Last Update Date | 02/27/2021
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Provider Practice Location Address
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Address Line | 2295 S VINEYARD AVE BLDG D
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City | ONTARIO
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State | CA
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Zip | 91761-7925
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Country | US
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Telephone | 909-724-3120
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Fax |
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Provider Business Mailing Address
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Address Line | 2367 VINEYARD ST
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City | UPLAND
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State | CA
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Zip | 91786-3570
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Country | US
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Telephone | 209-550-1889
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | 84088
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License Number State | CA
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