Provider Demographics
NPI:1104046242
Name:GOFORTH, SUSAN ALAINE (RPH)
Entity type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:ALAINE
Last Name:GOFORTH
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 37
Mailing Address - Street 2:
Mailing Address - City:WICKETT
Mailing Address - State:TX
Mailing Address - Zip Code:79788
Mailing Address - Country:US
Mailing Address - Phone:432-547-2018
Mailing Address - Fax:432-943-4464
Practice Address - Street 1:1201 S STOCKTON
Practice Address - Street 2:
Practice Address - City:MONAHANS
Practice Address - State:TX
Practice Address - Zip Code:79756
Practice Address - Country:US
Practice Address - Phone:432-943-4445
Practice Address - Fax:432-943-4464
Is Sole Proprietor?:No
Enumeration Date:2007-04-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX29901183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist