Provider Demographics
NPI:1639308224
Name:GOODWIN, CODY DOMENICK
Entity Type:Individual
Prefix:
First Name:CODY
Middle Name:DOMENICK
Last Name:GOODWIN
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 1:227 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:NH
Mailing Address - Zip Code:03102-4838
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:227 S MAIN ST
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:NH
Practice Address - Zip Code:03102-4838
Practice Address - Country:US
Practice Address - Phone:603-666-8521
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-05
Last Update Date:2009-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NHPT5932183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician