Basic Information
| Provider Information | |||||||||
| NPI: | 1457905127 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOODALL | ||||||||
| FirstName: | ANDREW | ||||||||
| MiddleName: | RAYMOND | ||||||||
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| Credential: | PHARMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 768 MICHIGAN AVE APT 303 | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432151954 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 3940 4TH AVE STE 150 | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921037193 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6195749700 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/30/2019 | ||||||||
| LastUpdateDate: | 07/13/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | 03438640 | OH | N | Pharmacy Service Providers | Pharmacist | 183500000X | 20561 | NV | N | Pharmacy Service Providers | Pharmacist | 183500000X | 82588 | CA | Y | Pharmacy Service Providers | Pharmacist |
No ID Information.