Provider Demographics
NPI:1316284961
Name:GOODMAN, MITCH
Entity type:Individual
Prefix:
First Name:MITCH
Middle Name:
Last Name:GOODMAN
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 1:3740 W HILLSBORO BLVD
Mailing Address - Street 2:
Mailing Address - City:DEERFIELD BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33442-9411
Mailing Address - Country:US
Mailing Address - Phone:954-427-0675
Mailing Address - Fax:954-427-0845
Practice Address - Street 1:3740 W HILLSBORO BLVD
Practice Address - Street 2:
Practice Address - City:DEERFIELD BEACH
Practice Address - State:FL
Practice Address - Zip Code:33442-9411
Practice Address - Country:US
Practice Address - Phone:954-427-0675
Practice Address - Fax:954-427-0845
Is Sole Proprietor?:No
Enumeration Date:2013-01-15
Last Update Date:2013-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS16588183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist