Provider Demographics
NPI:1104581974
Name:GOOD, QUINTIN
Entity type:Individual
Prefix:
First Name:QUINTIN
Middle Name:
Last Name:GOOD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1402 SAINT JOHN AVE
Mailing Address - Street 2:
Mailing Address - City:RUSTON
Mailing Address - State:LA
Mailing Address - Zip Code:71270-5244
Mailing Address - Country:US
Mailing Address - Phone:225-933-0666
Mailing Address - Fax:
Practice Address - Street 1:108 W CALIFORNIA AVE
Practice Address - Street 2:
Practice Address - City:RUSTON
Practice Address - State:LA
Practice Address - Zip Code:71270-5014
Practice Address - Country:US
Practice Address - Phone:318-255-1811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-05
Last Update Date:2021-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPST.024013183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist