Provider Demographics
NPI:1790505121
Name:GOODFRIEND, GERALD (RPH)
Entity type:Individual
Prefix:
First Name:GERALD
Middle Name:
Last Name:GOODFRIEND
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 1:24477 KERCHEVAL ST
Mailing Address - Street 2:
Mailing Address - City:SHERIDAN
Mailing Address - State:IN
Mailing Address - Zip Code:46069-9472
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:24477 KERCHEVAL ST
Practice Address - Street 2:
Practice Address - City:SHERIDAN
Practice Address - State:IN
Practice Address - Zip Code:46069-9472
Practice Address - Country:US
Practice Address - Phone:419-574-2003
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-11
Last Update Date:2024-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26030948A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist