Healthcare Provider Details

I. General information

NPI: 1477574978
Provider Name (Legal Business Name): GARY SEAN GOODMAN PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6000 QUIET GLOW AVE
LAS VEGAS NV
89139-6422
US

IV. Provider business mailing address

6000 QUIET GLOW AVE
LAS VEGAS NV
89139-6422
US

V. Phone/Fax

Practice location:
  • Phone: 702-263-8319
  • Fax:
Mailing address:
  • Phone: 702-263-8319
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P1200X
TaxonomyPharmacotherapy Pharmacist
License Number16949
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: