Provider Demographics
NPI:1700167806
Name:GODFREY, JOHN GLEN (RPH)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:GLEN
Last Name:GODFREY
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:PO BOX 97
Mailing Address - Street 2:
Mailing Address - City:LAURELVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43135-0097
Mailing Address - Country:US
Mailing Address - Phone:740-332-1833
Mailing Address - Fax:
Practice Address - Street 1:15986 STATE ROUTE 56
Practice Address - Street 2:
Practice Address - City:LAURELVILLE
Practice Address - State:OH
Practice Address - Zip Code:43135
Practice Address - Country:US
Practice Address - Phone:740-332-1833
Practice Address - Fax:740-332-1933
Is Sole Proprietor?:No
Enumeration Date:2011-09-01
Last Update Date:2011-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03319865183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist