Provider Demographics
NPI:1811549199
Name:GOODRUM, ERVIN (PHARMD)
Entity Type:Individual
Prefix:
First Name:ERVIN
Middle Name:
Last Name:GOODRUM
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:E.J.
Other - Middle Name:
Other - Last Name:GOODRUM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2807 DANIEL MCCALL DR APT 611
Mailing Address - Street 2:
Mailing Address - City:LUFKIN
Mailing Address - State:TX
Mailing Address - Zip Code:75904-7155
Mailing Address - Country:US
Mailing Address - Phone:936-715-8225
Mailing Address - Fax:
Practice Address - Street 1:903 W FRANK AVE
Practice Address - Street 2:
Practice Address - City:LUFKIN
Practice Address - State:TX
Practice Address - Zip Code:75904-3318
Practice Address - Country:US
Practice Address - Phone:936-634-3006
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-16
Last Update Date:2019-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX64847183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist