Provider Demographics
NPI:1336769579
Name:GOOD, MARK J SR
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:J
Last Name:GOOD
Suffix:SR
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 1:2145 SE CRABAPPLE CT
Mailing Address - Street 2:
Mailing Address - City:WAUKEE
Mailing Address - State:IA
Mailing Address - Zip Code:50263-9550
Mailing Address - Country:US
Mailing Address - Phone:515-570-4106
Mailing Address - Fax:
Practice Address - Street 1:510 WEST MCCLANE ST.
Practice Address - Street 2:
Practice Address - City:OSCEOLA
Practice Address - State:IA
Practice Address - Zip Code:50213
Practice Address - Country:US
Practice Address - Phone:641-342-2125
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-17
Last Update Date:2020-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA16564183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist