Provider Demographics
NPI:1720410160
Name:GOODRICH, MICHELLE DIANNE (RPH)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:DIANNE
Last Name:GOODRICH
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:829 N 1250 EAST RD
Mailing Address - Street 2:
Mailing Address - City:TAYLORVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62568-8133
Mailing Address - Country:US
Mailing Address - Phone:217-824-8719
Mailing Address - Fax:
Practice Address - Street 1:108 S POPLAR ST
Practice Address - Street 2:
Practice Address - City:PANA
Practice Address - State:IL
Practice Address - Zip Code:62557-1404
Practice Address - Country:US
Practice Address - Phone:217-562-2770
Practice Address - Fax:217-562-2778
Is Sole Proprietor?:No
Enumeration Date:2013-08-08
Last Update Date:2022-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.289740183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist