Healthcare Provider Details

I. General information

NPI: 1417948464
Provider Name (Legal Business Name): MORT GOLDMAN PHARM.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/31/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9500 EUCLID AVE QQB-5
CLEVELAND OH
44195-0001
US

IV. Provider business mailing address

24116 E GROVELAND RD
BEACHWOOD OH
44122-1213
US

V. Phone/Fax

Practice location:
  • Phone: 216-444-1127
  • Fax: 216-444-4380
Mailing address:
  • Phone: 216-444-1127
  • Fax: 216-444-4380

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P1200X
TaxonomyPharmacotherapy Pharmacist
License Number03-2-15163
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: