Provider Demographics
NPI:1083996136
Name:GODBOUT, PETER (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:
Last Name:GODBOUT
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 E MAIN RD
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:RI
Mailing Address - Zip Code:02842-4912
Mailing Address - Country:US
Mailing Address - Phone:401-847-8520
Mailing Address - Fax:401-849-9433
Practice Address - Street 1:12 E MAIN RD
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:RI
Practice Address - Zip Code:02842-4912
Practice Address - Country:US
Practice Address - Phone:401-847-8520
Practice Address - Fax:401-849-9433
Is Sole Proprietor?:No
Enumeration Date:2011-09-14
Last Update Date:2011-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIRPH04339183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist