Provider Demographics
NPI:1760901805
Name:GOLDSBERRY, THEODORE (RPH)
Entity Type:Individual
Prefix:
First Name:THEODORE
Middle Name:
Last Name:GOLDSBERRY
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 1:2875 ASPEN VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:BETTENDORF
Mailing Address - State:IA
Mailing Address - Zip Code:52722-8101
Mailing Address - Country:US
Mailing Address - Phone:563-332-0358
Mailing Address - Fax:
Practice Address - Street 1:2875 ASPEN VALLEY DR
Practice Address - Street 2:
Practice Address - City:BETTENDORF
Practice Address - State:IA
Practice Address - Zip Code:52722-8101
Practice Address - Country:US
Practice Address - Phone:563-332-0358
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-09
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA18572183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist