Provider Demographics
NPI:1942567425
Name:GOFF, MARK AARON
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:AARON
Last Name:GOFF
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7545 HAMPTON AVE APT 109
Mailing Address - Street 2:
Mailing Address - City:WEST HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90046-5597
Mailing Address - Country:US
Mailing Address - Phone:323-200-4777
Mailing Address - Fax:
Practice Address - Street 1:7545 HAMPTON AVE APT 109
Practice Address - Street 2:
Practice Address - City:WEST HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:90046-5597
Practice Address - Country:US
Practice Address - Phone:323-200-4777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-20
Last Update Date:2012-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAIR 60151855183500000X
IDE14889183500000X
CAINT 27392183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist