Provider Demographics
NPI:1750658688
Name:GOEDDAEUS, GEORGE W
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:W
Last Name:GOEDDAEUS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5400 WALDORF RD
Mailing Address - Street 2:
Mailing Address - City:DELTON
Mailing Address - State:MI
Mailing Address - Zip Code:49046-7786
Mailing Address - Country:US
Mailing Address - Phone:269-623-5910
Mailing Address - Fax:
Practice Address - Street 1:5815 GULL RD
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49048-1094
Practice Address - Country:US
Practice Address - Phone:269-226-9433
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-21
Last Update Date:2011-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302021999183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist