Provider Demographics
NPI:1801187992
Name:GOODLAXSON, J DAVID (RPH)
Entity type:Individual
Prefix:MR
First Name:J
Middle Name:DAVID
Last Name:GOODLAXSON
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 425
Mailing Address - Street 2:
Mailing Address - City:GALESBURG
Mailing Address - State:IL
Mailing Address - Zip Code:61402-0425
Mailing Address - Country:US
Mailing Address - Phone:309-344-2814
Mailing Address - Fax:309-344-2814
Practice Address - Street 1:3033 LINCOLN PARK DR
Practice Address - Street 2:
Practice Address - City:GALESBURG
Practice Address - State:IL
Practice Address - Zip Code:61401-1127
Practice Address - Country:US
Practice Address - Phone:309-344-2814
Practice Address - Fax:309-344-2814
Is Sole Proprietor?:No
Enumeration Date:2011-04-25
Last Update Date:2011-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051030187183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist