Provider Demographics
NPI:1134441355
Name:GOODRICH, MARK T (RPH)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:T
Last Name:GOODRICH
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2809 NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81501-5105
Mailing Address - Country:US
Mailing Address - Phone:970-243-4338
Mailing Address - Fax:
Practice Address - Street 1:2809 NORTH AVE
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81501-5105
Practice Address - Country:US
Practice Address - Phone:970-243-4338
Practice Address - Fax:970-257-9551
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-16
Last Update Date:2010-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO97451835P1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy