Healthcare Provider Details

I. General information

NPI: 1104046242
Provider Name (Legal Business Name): SUSAN ALAINE GOFORTH RPH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/30/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 S STOCKTON
MONAHANS TX
79756
US

IV. Provider business mailing address

PO BOX 37
WICKETT TX
79788
US

V. Phone/Fax

Practice location:
  • Phone: 432-943-4445
  • Fax: 432-943-4464
Mailing address:
  • Phone: 432-547-2018
  • Fax: 432-943-4464

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number29901
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: