Provider Demographics
NPI:1629425012
Name:GOODSON, SALLY LYNNE (RPH)
Entity Type:Individual
Prefix:MS
First Name:SALLY
Middle Name:LYNNE
Last Name:GOODSON
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 1:2622 W CENTRAL AVE
Mailing Address - Street 2:SUITE 302
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67203-4969
Mailing Address - Country:US
Mailing Address - Phone:316-265-3300
Mailing Address - Fax:316-265-3304
Practice Address - Street 1:2622 W CENTRAL AVE
Practice Address - Street 2:SUITE 302
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67203-4969
Practice Address - Country:US
Practice Address - Phone:316-265-3300
Practice Address - Fax:316-265-3304
Is Sole Proprietor?:No
Enumeration Date:2016-05-16
Last Update Date:2016-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS96771835G0303X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835G0303XPharmacy Service ProvidersPharmacistGeriatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS709829OtherNABP