1366789372 NPI number — DR. BRYAN JOSEPH GOODMAN PHARM D

Table of content: DR. BRYAN JOSEPH GOODMAN PHARM D (NPI 1366789372)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366789372 NPI number — DR. BRYAN JOSEPH GOODMAN PHARM D

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GOODMAN
Provider First Name:
BRYAN
Provider Middle Name:
JOSEPH
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PHARM D
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1366789372
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/10/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
15 LAUREL CANYON VILLAGE CIR
Provider Second Line Business Mailing Address:
118
Provider Business Mailing Address City Name:
CANTON
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30114-4469
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-479-3711
Provider Business Mailing Address Fax Number:
770-479-3777

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
15 LAUREL CANYON VILLAGE CIR
Provider Second Line Business Practice Location Address:
118
Provider Business Practice Location Address City Name:
CANTON
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30114-4469
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-479-3711
Provider Business Practice Location Address Fax Number:
770-479-3777
Provider Enumeration Date:
01/10/2013

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 183500000X , with the licence number:  RPH024776 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2025 www.npivalidator.com