Provider Demographics
NPI:1891898136
Name:GOODKIN, JACQUELINE DIANE (PHARMD)
Entity Type:Individual
Prefix:MS
First Name:JACQUELINE
Middle Name:DIANE
Last Name:GOODKIN
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 1:1454 RIVER RD S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-4325
Mailing Address - Country:US
Mailing Address - Phone:701-239-3700
Mailing Address - Fax:
Practice Address - Street 1:2101 ELM ST N
Practice Address - Street 2:
Practice Address - City:FARGP
Practice Address - State:ND
Practice Address - Zip Code:58102
Practice Address - Country:US
Practice Address - Phone:701-239-3700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND30231835P1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy