Provider Demographics
NPI:1508155078
Name:GODINES, ELLEN A
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:A
Last Name:GODINES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9801 MANCHACA RD
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78748-6212
Mailing Address - Country:US
Mailing Address - Phone:512-292-1066
Mailing Address - Fax:
Practice Address - Street 1:9801 MANCHACA RD
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78748-6212
Practice Address - Country:US
Practice Address - Phone:512-292-1066
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-05
Last Update Date:2011-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX34429183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist