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General NPI Number Information
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NPI Number | 1871035659
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Entity Type | Organization
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Legal Business Name | GOODMAN PHARMACY, LLC
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Dates
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Enumeration Date | 11/10/2016
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Last Update Date | 11/10/2016
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Provider Practice Location Address
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Address Line | 6888 GOODMAN RD STE 104
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City | OLIVE BRANCH
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State | MS
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Zip | 38654-8759
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Country | US
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Telephone | 662-580-1035
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Fax |
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Provider Business Mailing Address
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Address Line | 6888 GOODMAN RD STE 104
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City | OLIVE BRANCH
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State | MS
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Zip | 38654-8759
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PIC/MANAGING MEMBER
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Name | MARY GLENN
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Credential |
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Telephone | 662-580-1035
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number | 12429
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License Number State | MS
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