Provider Demographics
NPI:1487867651
Name:GOODYEAR, DAVID J
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:J
Last Name:GOODYEAR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3404 S MARTIN LUTHER KING JR BLVD
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48910-4387
Mailing Address - Country:US
Mailing Address - Phone:517-393-5784
Mailing Address - Fax:
Practice Address - Street 1:3404 S MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48910-4387
Practice Address - Country:US
Practice Address - Phone:517-393-5784
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-07
Last Update Date:2011-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302025693183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist