Provider Demographics
NPI:1952684110
Name:GOODRICH, JEANIE E (RPH)
Entity Type:Individual
Prefix:
First Name:JEANIE
Middle Name:E
Last Name:GOODRICH
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10927 PASQUALE DR NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87114-5576
Mailing Address - Country:US
Mailing Address - Phone:505-301-1027
Mailing Address - Fax:505-822-1889
Practice Address - Street 1:200A TRAMWAY BLVD SE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87123-3934
Practice Address - Country:US
Practice Address - Phone:505-301-1027
Practice Address - Fax:505-822-1889
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-23
Last Update Date:2011-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM5221183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist