Provider Demographics
NPI:1689727398
Name:GOODMAN, ROBERT CARROLL JR (PHARMD, BCPS)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:CARROLL
Last Name:GOODMAN
Suffix:JR
Gender:M
Credentials:PHARMD, BCPS
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Mailing Address - Street 1:908 WALLACE AVE
Mailing Address - Street 2:SUITE 105, MIDWAY PHARMACY
Mailing Address - City:LEITCHFIELD
Mailing Address - State:KY
Mailing Address - Zip Code:42754-1479
Mailing Address - Country:US
Mailing Address - Phone:270-259-8400
Mailing Address - Fax:270-230-8517
Practice Address - Street 1:908 WALLACE AVE
Practice Address - Street 2:SUITE 105, MIDWAY PHARMACY
Practice Address - City:LEITCHFIELD
Practice Address - State:KY
Practice Address - Zip Code:42754-1479
Practice Address - Country:US
Practice Address - Phone:270-259-8400
Practice Address - Fax:270-230-8517
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
KY009475183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY009475OtherPHARMACIST LICENSE