Provider Demographics
NPI:1669785291
Name:GOLDMAN, IRA STANLEY (RPH)
Entity type:Individual
Prefix:MR
First Name:IRA
Middle Name:STANLEY
Last Name:GOLDMAN
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 1:4230 W MCDOWELL RD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85009-2096
Mailing Address - Country:US
Mailing Address - Phone:602-415-5733
Mailing Address - Fax:602-415-5727
Practice Address - Street 1:4230 W MCDOWELL RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85009-2096
Practice Address - Country:US
Practice Address - Phone:602-415-5733
Practice Address - Fax:602-415-5727
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-25
Last Update Date:2010-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSO11000183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist