Provider Demographics
NPI:1518034685
Name:GODDETTE, GARRY L (RPH)
Entity Type:Individual
Prefix:MR
First Name:GARRY
Middle Name:L
Last Name:GODDETTE
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 1:404 S PORT DR
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85233-6715
Mailing Address - Country:US
Mailing Address - Phone:404-275-5571
Mailing Address - Fax:
Practice Address - Street 1:444 N 44TH ST STE 400
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85008-7629
Practice Address - Country:US
Practice Address - Phone:602-629-1584
Practice Address - Fax:602-914-5906
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ14661183500000X
PARP043822R183500000X
CT5216183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist