Provider Demographics
NPI:1356727911
Name:GONZALES, DANE DAVID (PHARMD)
Entity type:Individual
Prefix:
First Name:DANE
Middle Name:DAVID
Last Name:GONZALES
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1570 E FAIRVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-1821
Mailing Address - Country:US
Mailing Address - Phone:208-888-0034
Mailing Address - Fax:208-887-1332
Practice Address - Street 1:1570 E FAIRVIEW AVE
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-1821
Practice Address - Country:US
Practice Address - Phone:208-888-0034
Practice Address - Fax:208-887-1332
Is Sole Proprietor?:No
Enumeration Date:2015-08-06
Last Update Date:2023-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP7305183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist