Provider Demographics
NPI:1871035659
Name:GOODMAN PHARMACY, LLC
Entity Type:Organization
Organization Name:GOODMAN PHARMACY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PIC/MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:GLENN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-580-1035
Mailing Address - Street 1:6888 GOODMAN RD STE 104
Mailing Address - Street 2:
Mailing Address - City:OLIVE BRANCH
Mailing Address - State:MS
Mailing Address - Zip Code:38654-8759
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6888 GOODMAN RD STE 104
Practice Address - Street 2:
Practice Address - City:OLIVE BRANCH
Practice Address - State:MS
Practice Address - Zip Code:38654-8759
Practice Address - Country:US
Practice Address - Phone:662-580-1035
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-10
Last Update Date:2016-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS124293336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy