Provider Demographics
NPI:1508908963
Name:GOODMAN, JENNIE (RPH)
Entity Type:Individual
Prefix:MRS
First Name:JENNIE
Middle Name:
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 1:1510 JENKINS AVE
Mailing Address - Street 2:
Mailing Address - City:BONIFAY
Mailing Address - State:FL
Mailing Address - Zip Code:32425-3159
Mailing Address - Country:US
Mailing Address - Phone:850-547-0414
Mailing Address - Fax:
Practice Address - Street 1:17324 MAIN ST N
Practice Address - Street 2:
Practice Address - City:BLOUNTSTOWN
Practice Address - State:FL
Practice Address - Zip Code:32424-1763
Practice Address - Country:US
Practice Address - Phone:850-674-4557
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS14766183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist