MEDICARE: MR. GEORGE EDWARD GOFORTH II

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	3435	SC

General Provider Information

NPI Number	:	1306145024
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. GEORGE EDWARD GOFORTH II

Provider Business Mailing Address
First Line	:	105 SEDGEWOOD COURT
Second Line	:
City	:	EASLEY
State	:	SC
Zip	:	29642
Country	:	US
Telephone Number	:	864-269-9279
Fax Number	:	864-220-9997

Provider Business Practice Location Address
First Line	:	3455 HIGHWAY 153
Second Line	:
City	:	PIEDMONT
State	:	SC
Zip	:	29673-7725
Country	:	US
Telephone Number	:	864-220-9992
Fax Number	:	864-220-2967

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/21/2011
Last Update Date	:	03/21/2011

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