Provider Demographics
NPI:1215563515
Name:GOODMAN, TINA H (RPH)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:H
Last Name:GOODMAN
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8425 SNOW GOOSE WAY
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76118-2001
Mailing Address - Country:US
Mailing Address - Phone:817-966-0206
Mailing Address - Fax:
Practice Address - Street 1:8425 SNOW GOOSE WAY
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76118-2001
Practice Address - Country:US
Practice Address - Phone:817-966-0206
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-18
Last Update Date:2021-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX30044183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist