Provider Demographics
NPI:1821780123
Name:GODFREY, MIRANDA RENEE (PHARMD)
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:RENEE
Last Name:GODFREY
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:337 OUR LN
Mailing Address - Street 2:
Mailing Address - City:KEARNEYSVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:25430-3835
Mailing Address - Country:US
Mailing Address - Phone:304-279-5082
Mailing Address - Fax:
Practice Address - Street 1:510 BUTLER AVE
Practice Address - Street 2:
Practice Address - City:MARTINSBURG
Practice Address - State:WV
Practice Address - Zip Code:25405-9991
Practice Address - Country:US
Practice Address - Phone:304-263-0811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-24
Last Update Date:2023-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA02022209491835P0018X, 183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
No183500000XPharmacy Service ProvidersPharmacist