Provider Demographics
NPI:1972817708
Name:GOODSON, MARY ELLEN (RPH)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ELLEN
Last Name:GOODSON
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:DUPUIS
Other - Last Name:GOODSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RPH
Mailing Address - Street 1:7009 LAKE COMITE DR
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70818-6716
Mailing Address - Country:US
Mailing Address - Phone:225-261-1619
Mailing Address - Fax:
Practice Address - Street 1:15046 MARKET ST
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70817-1384
Practice Address - Country:US
Practice Address - Phone:225-753-2700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-04
Last Update Date:2010-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA11047183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist