Provider Demographics
NPI:1780805648
Name:GODAIR, GARY L (RPH)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:L
Last Name:GODAIR
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 443
Mailing Address - Street 2:
Mailing Address - City:DERIDDER
Mailing Address - State:LA
Mailing Address - Zip Code:70634-0443
Mailing Address - Country:US
Mailing Address - Phone:337-239-3474
Mailing Address - Fax:337-238-2575
Practice Address - Street 1:702 N FRUSHA DR
Practice Address - Street 2:
Practice Address - City:DERIDDER
Practice Address - State:LA
Practice Address - Zip Code:70634-3222
Practice Address - Country:US
Practice Address - Phone:337-239-3474
Practice Address - Fax:337-238-2575
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA9106183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist