Provider Demographics
NPI:1043327604
Name:GOODWIN, LAURIE B
Entity type:Individual
Prefix:
First Name:LAURIE
Middle Name:B
Last Name:GOODWIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 KNAUF RD
Mailing Address - Street 2:
Mailing Address - City:OWEGO
Mailing Address - State:NY
Mailing Address - Zip Code:13827-1742
Mailing Address - Country:US
Mailing Address - Phone:607-759-7804
Mailing Address - Fax:
Practice Address - Street 1:21 N MAIN ST
Practice Address - Street 2:
Practice Address - City:NEWARK VALLEY
Practice Address - State:NY
Practice Address - Zip Code:13811-3607
Practice Address - Country:US
Practice Address - Phone:607-642-3355
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-23
Last Update Date:2021-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY037486-1183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist