MEDICARE: MR. RICKY G GONZALEZ I R.PH.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	42075	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	42075	OTHER	TX	PHARMACY

General Provider Information

NPI Number	:	1669524229
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. RICKY G GONZALEZ I R.PH.

Provider Business Mailing Address
First Line	:	21303 PLAZA DE CADIZ
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78257-1657
Country	:	US
Telephone Number	:	210-867-9167
Fax Number	:

Provider Business Practice Location Address
First Line	:	11707 HUEBNER RD
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78230-1205
Country	:	US
Telephone Number	:	210-558-7138
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/16/2007
Last Update Date	:	12/21/2022

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