Provider Demographics
NPI:1114924198
Name:GOETZ, BOB ELMER (RPH)
Entity Type:Individual
Prefix:
First Name:BOB
Middle Name:ELMER
Last Name:GOETZ
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 1:2495 WILDWOOD RDG
Mailing Address - Street 2:
Mailing Address - City:RED WING
Mailing Address - State:MN
Mailing Address - Zip Code:55066-4022
Mailing Address - Country:US
Mailing Address - Phone:651-388-4109
Mailing Address - Fax:
Practice Address - Street 1:401 WEST 3RD ST.
Practice Address - Street 2:
Practice Address - City:RED WING
Practice Address - State:MN
Practice Address - Zip Code:55066-4022
Practice Address - Country:US
Practice Address - Phone:651-388-4109
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-05
Last Update Date:2011-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN111549-9183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist