Provider Demographics
NPI:1053987123
Name:GOODMAN, LESLIE FLOYD
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:FLOYD
Last Name:GOODMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2350 HARPER ST
Mailing Address - Street 2:
Mailing Address - City:CHOCTAW
Mailing Address - State:OK
Mailing Address - Zip Code:73020-8087
Mailing Address - Country:US
Mailing Address - Phone:405-390-3611
Mailing Address - Fax:405-390-3670
Practice Address - Street 1:2350 HARPER ST
Practice Address - Street 2:
Practice Address - City:CHOCTAW
Practice Address - State:OK
Practice Address - Zip Code:73020-8087
Practice Address - Country:US
Practice Address - Phone:405-390-3670
Practice Address - Fax:405-390-3670
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-31
Last Update Date:2021-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK9854183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist