Provider Demographics
NPI:1780712323
Name:GOODMAN DRUGS OF FL CORP
Entity type:Organization
Organization Name:GOODMAN DRUGS OF FL CORP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHERINE
Authorized Official - Middle Name:
Authorized Official - Last Name:BAHNA
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:954-637-8855
Mailing Address - Street 1:1078 S POWERLINE ROAD
Mailing Address - Street 2:
Mailing Address - City:DEERFIELD BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33442
Mailing Address - Country:US
Mailing Address - Phone:954-637-8855
Mailing Address - Fax:855-315-7478
Practice Address - Street 1:1234 NE 4TH AVENUE
Practice Address - Street 2:SUITE C
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33304
Practice Address - Country:US
Practice Address - Phone:954-764-6257
Practice Address - Fax:954-764-3175
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-02
Last Update Date:2016-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPH 124313336C0003X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1009922OtherNABP
FL1070882OtherNABP
FL1022181-00Medicaid