Provider Demographics
NPI:1528274610
Name:GOODALL, CHARLES LOWELL (RPH)
Entity type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:LOWELL
Last Name:GOODALL
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 JAMES DR
Mailing Address - Street 2:
Mailing Address - City:HAWTHORN WOODS
Mailing Address - State:IL
Mailing Address - Zip Code:60047-9232
Mailing Address - Country:US
Mailing Address - Phone:847-540-7418
Mailing Address - Fax:
Practice Address - Street 1:15 JAMES DR
Practice Address - Street 2:
Practice Address - City:HAWTHORN WOODS
Practice Address - State:IL
Practice Address - Zip Code:60047-9232
Practice Address - Country:US
Practice Address - Phone:847-540-7418
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0051-036119183500000X
TX27996183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist