Healthcare Provider Details

I. General information

NPI: 1689727398
Provider Name (Legal Business Name): ROBERT CARROLL GOODMAN JR. PHARMD., BCPS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/18/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

908 WALLACE AVE SUITE 105, MIDWAY PHARMACY
LEITCHFIELD KY
42754-1479
US

IV. Provider business mailing address

908 WALLACE AVE SUITE 105, MIDWAY PHARMACY
LEITCHFIELD KY
42754-1479
US

V. Phone/Fax

Practice location:
  • Phone: 270-259-8400
  • Fax: 270-230-8517
Mailing address:
  • Phone: 270-259-8400
  • Fax: 270-230-8517

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number009475
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: