Provider Demographics
NPI:1205053402
Name:GOETHE, PAULA MARIE (PHT)
Entity type:Individual
Prefix:MRS
First Name:PAULA
Middle Name:MARIE
Last Name:GOETHE
Suffix:
Gender:F
Credentials:PHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:903 CEDAR RIDGE CT
Mailing Address - Street 2:
Mailing Address - City:MAHOMET
Mailing Address - State:IL
Mailing Address - Zip Code:61853-8981
Mailing Address - Country:US
Mailing Address - Phone:217-586-3923
Mailing Address - Fax:
Practice Address - Street 1:108 N MARKET ST
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:IL
Practice Address - Zip Code:61856-1636
Practice Address - Country:US
Practice Address - Phone:217-762-4766
Practice Address - Fax:217-762-9401
Is Sole Proprietor?:No
Enumeration Date:2007-04-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist