Provider Demographics
NPI:1043236193
Name:RODGERS, CHARLES L (RPH)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:L
Last Name:RODGERS
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 N WINFREE ST
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:TX
Mailing Address - Zip Code:77535-2653
Mailing Address - Country:US
Mailing Address - Phone:936-258-7641
Mailing Address - Fax:936-258-4444
Practice Address - Street 1:201 N WINFREE ST
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:TX
Practice Address - Zip Code:77535-2653
Practice Address - Country:US
Practice Address - Phone:936-258-7641
Practice Address - Fax:936-258-4444
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX17994183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX142865Medicaid