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General NPI Number Information
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NPI Number | 1174669733
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Entity Type | Organization
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Legal Business Name | LEROY M GODFREY
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Dates
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Enumeration Date | 01/30/2007
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Last Update Date | 05/20/2014
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Provider Practice Location Address
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Address Line | 510 GARIBALDI AVE
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City | GARIBALDI
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State | OR
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Zip | 97118-1513
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Country | US
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Telephone | 503-322-3456
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Fax | 503-322-0003
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Provider Business Mailing Address
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Address Line | PO BOX 287
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City | GARIBALDI
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State | OR
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Zip | 97118-0287
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Country | US
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Telephone | 503-322-3456
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Fax | 503-322-0003
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Authorized Official
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Title or Position | OWNER
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Name | LEROY GODFREY
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Credential | RPH
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Telephone | 503-322-3456
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 333600000X
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Taxonomy Name | Pharmacy
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number | RP0000226
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License Number State | OR
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