Provider Demographics
NPI:1528484011
Name:GOEDEKEN, GRETCHEN
Entity type:Individual
Prefix:
First Name:GRETCHEN
Middle Name:
Last Name:GOEDEKEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7501 APOLLO DR
Mailing Address - Street 2:
Mailing Address - City:JOSHUA
Mailing Address - State:TX
Mailing Address - Zip Code:76058-4329
Mailing Address - Country:US
Mailing Address - Phone:817-983-4072
Mailing Address - Fax:
Practice Address - Street 1:7501 APOLLO DR
Practice Address - Street 2:
Practice Address - City:JOSHUA
Practice Address - State:TX
Practice Address - Zip Code:76058-4329
Practice Address - Country:US
Practice Address - Phone:817-983-4072
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-09
Last Update Date:2014-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX44578183500000X
NE10420183500000X
AZS009253183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist