Provider Demographics
NPI:1679264873
Name:GOMEZ, JUSTINAH
Entity type:Individual
Prefix:
First Name:JUSTINAH
Middle Name:
Last Name:GOMEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4103 S OAK VIEW ST
Mailing Address - Street 2:
Mailing Address - City:VISALIA
Mailing Address - State:CA
Mailing Address - Zip Code:93277-5190
Mailing Address - Country:US
Mailing Address - Phone:559-741-3078
Mailing Address - Fax:
Practice Address - Street 1:1710 N FARMERSVILLE BLVD
Practice Address - Street 2:
Practice Address - City:FARMERSVILLE
Practice Address - State:CA
Practice Address - Zip Code:93223-2306
Practice Address - Country:US
Practice Address - Phone:559-747-3317
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-17
Last Update Date:2023-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA128286183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician