Provider Demographics
NPI:1366054553
Name:GOODMAN, ALEXA JEAN
Entity type:Individual
Prefix:
First Name:ALEXA
Middle Name:JEAN
Last Name:GOODMAN
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 1:1350 S GREENFIELD RD UNIT 1155
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85206-3498
Mailing Address - Country:US
Mailing Address - Phone:801-910-9861
Mailing Address - Fax:
Practice Address - Street 1:13733 N FOUNTAIN HILLS BLVD
Practice Address - Street 2:
Practice Address - City:FOUNTAIN HILLS
Practice Address - State:AZ
Practice Address - Zip Code:85268-3730
Practice Address - Country:US
Practice Address - Phone:480-837-1690
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-19
Last Update Date:2020-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS024811183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist