Provider Demographics
NPI:1497167068
Name:GOODKIN, RYAN
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:GOODKIN
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 1:101 N FEDERAL HWY
Mailing Address - Street 2:
Mailing Address - City:LAKE WORTH
Mailing Address - State:FL
Mailing Address - Zip Code:33460-3435
Mailing Address - Country:US
Mailing Address - Phone:561-585-4677
Mailing Address - Fax:561-588-8562
Practice Address - Street 1:101 N FEDERAL HWY
Practice Address - Street 2:
Practice Address - City:LAKE WORTH
Practice Address - State:FL
Practice Address - Zip Code:33460-3435
Practice Address - Country:US
Practice Address - Phone:561-585-4677
Practice Address - Fax:561-588-8562
Is Sole Proprietor?:No
Enumeration Date:2014-05-29
Last Update Date:2014-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS45058183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist