Provider Demographics
NPI:1124422449
Name:GOEDEKER, BRADLEY JACOB (PHARMD)
Entity type:Individual
Prefix:MR
First Name:BRADLEY
Middle Name:JACOB
Last Name:GOEDEKER
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8320 MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46227-6066
Mailing Address - Country:US
Mailing Address - Phone:317-881-7061
Mailing Address - Fax:317-881-7658
Practice Address - Street 1:8320 MADISON AVE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46227-6066
Practice Address - Country:US
Practice Address - Phone:317-881-7061
Practice Address - Fax:317-881-7658
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-15
Last Update Date:2014-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26022393A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist