Provider Demographics
NPI:1184351306
Name:GOODMAN, TARA
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:GOODMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2204 BELMONT DR
Mailing Address - Street 2:
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42301-5884
Mailing Address - Country:US
Mailing Address - Phone:618-606-1044
Mailing Address - Fax:
Practice Address - Street 1:2630 FREDERICA ST
Practice Address - Street 2:
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42301-5440
Practice Address - Country:US
Practice Address - Phone:270-926-4977
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-07
Last Update Date:2022-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY0229361835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist