Basic Information
| Provider Information | |||||||||
| NPI: | 1750890927 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SUGARMAN | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | GOODSON | ||||||||
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| Credential: | PHARMD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GOODSON | ||||||||
| OtherFirstName: | KELLY | ||||||||
| OtherMiddleName: | MAREE | ||||||||
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| OtherCredential: | PHARMD | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 124 ISLAND LN | ||||||||
| Address2: | |||||||||
| City: | MOORESVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 281177471 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1601 BRENNER AVE | ||||||||
| Address2: | |||||||||
| City: | SALISBURY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 281442515 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8007069126 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2017 | ||||||||
| LastUpdateDate: | 09/20/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1835P0018X | 22170 | NC | Y | Pharmacy Service Providers | Pharmacist | Pharmacist Clinician (PhC)/ Clinical Pharmacy Specialist |
No ID Information.