Provider Demographics
NPI:1992116578
Name:GODBOUT, MARK (RPH)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:GODBOUT
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 1:781 SOUTH HIGHWAY 49
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:CA
Mailing Address - Zip Code:95642
Mailing Address - Country:US
Mailing Address - Phone:209-223-9670
Mailing Address - Fax:
Practice Address - Street 1:781 SOUTH HIGHWAY 49
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:CA
Practice Address - Zip Code:95642
Practice Address - Country:US
Practice Address - Phone:209-223-9640
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-16
Last Update Date:2014-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA30226183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist