Provider Demographics
NPI:1720680473
Name:GODWIN, DALE ALAN (RPH)
Entity type:Individual
Prefix:
First Name:DALE
Middle Name:ALAN
Last Name:GODWIN
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 1:699 DOCKERY CREEK RD
Mailing Address - Street 2:
Mailing Address - City:YOUNG HARRIS
Mailing Address - State:GA
Mailing Address - Zip Code:30582-3760
Mailing Address - Country:US
Mailing Address - Phone:706-897-6836
Mailing Address - Fax:
Practice Address - Street 1:WALMART 3485
Practice Address - Street 2:2257 HWY 515
Practice Address - City:BLAIRSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30512
Practice Address - Country:US
Practice Address - Phone:706-835-2833
Practice Address - Fax:706-835-2840
Is Sole Proprietor?:No
Enumeration Date:2020-11-09
Last Update Date:2020-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH018229183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GARPH018229OtherGEORGIA PHARMACY LICENSE