Provider Demographics
NPI:1679874036
Name:GOODWIN, SAMUEL ERWIN (MBA, CPHT)
Entity Type:Individual
Prefix:MR
First Name:SAMUEL
Middle Name:ERWIN
Last Name:GOODWIN
Suffix:
Gender:M
Credentials:MBA, CPHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7290 55TH AVE E
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34203-8002
Mailing Address - Country:US
Mailing Address - Phone:941-727-8412
Mailing Address - Fax:941-727-8195
Practice Address - Street 1:7290 55TH AVE E
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34203-8002
Practice Address - Country:US
Practice Address - Phone:941-727-8412
Practice Address - Fax:941-727-8195
Is Sole Proprietor?:No
Enumeration Date:2010-11-16
Last Update Date:2010-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRPT00529183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
4701-0109-0250-425OtherPTCB