Provider Demographics
NPI:1457454720
Name:GOODSON, PHILLIP D (RPH)
Entity Type:Individual
Prefix:MR
First Name:PHILLIP
Middle Name:D
Last Name:GOODSON
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:PO BOX 204
Mailing Address - Street 2:
Mailing Address - City:DAWSONVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30534-0004
Mailing Address - Country:US
Mailing Address - Phone:706-265-2020
Mailing Address - Fax:706-265-2987
Practice Address - Street 1:159 HIGHWAY 53 WEST
Practice Address - Street 2:
Practice Address - City:DAWSONVILLE
Practice Address - State:GA
Practice Address - Zip Code:30534-0004
Practice Address - Country:US
Practice Address - Phone:706-265-2020
Practice Address - Fax:706-265-2987
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH010965183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000119677AMedicaid
GA000119677AMedicaid