Provider Demographics
NPI:1710202189
Name:GOODMAN, MITCHELL H (RPH)
Entity Type:Individual
Prefix:
First Name:MITCHELL
Middle Name:H
Last Name:GOODMAN
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 1:58 OHIO AVE
Mailing Address - Street 2:
Mailing Address - City:MASSAPEQUA
Mailing Address - State:NY
Mailing Address - Zip Code:11758-4834
Mailing Address - Country:US
Mailing Address - Phone:516-799-3196
Mailing Address - Fax:516-487-8729
Practice Address - Street 1:665 MIDDLE NECK RD
Practice Address - Street 2:
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11023-1216
Practice Address - Country:US
Practice Address - Phone:516-466-7700
Practice Address - Fax:516-487-8729
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-29
Last Update Date:2010-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY029185183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist