Provider Demographics
NPI:1659650786
Name:GODSHALL, DAVID MICHAEL (RPH)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:MICHAEL
Last Name:GODSHALL
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 1:118 SOUTH MADISON STREET
Mailing Address - Street 2:
Mailing Address - City:WAUPUN
Mailing Address - State:WI
Mailing Address - Zip Code:53963
Mailing Address - Country:US
Mailing Address - Phone:920-324-5649
Mailing Address - Fax:
Practice Address - Street 1:20 W PIONEER RD
Practice Address - Street 2:
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54935-6152
Practice Address - Country:US
Practice Address - Phone:920-907-0556
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-07
Last Update Date:2011-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI9119183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist