Provider Demographics
NPI:1548678550
Name:GOENNER, RICHARD JOHN
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:JOHN
Last Name:GOENNER
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 1:9362 RIVER RD SE
Mailing Address - Street 2:
Mailing Address - City:CLEAR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55319-9309
Mailing Address - Country:US
Mailing Address - Phone:320-241-6643
Mailing Address - Fax:
Practice Address - Street 1:1811 OLD HIGHWAY 8 NW
Practice Address - Street 2:
Practice Address - City:NEW BRIGHTON
Practice Address - State:MN
Practice Address - Zip Code:55112-1828
Practice Address - Country:US
Practice Address - Phone:651-639-0608
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-23
Last Update Date:2014-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1180701835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist