Provider Demographics
NPI:1063835023
Name:DODGE, ELIZABETH (PHARMD)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:DODGE
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4835 KIETZKE LN
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89509-6549
Mailing Address - Country:US
Mailing Address - Phone:775-829-7922
Mailing Address - Fax:775-829-8202
Practice Address - Street 1:4835 KIETZKE LN
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89509-6549
Practice Address - Country:US
Practice Address - Phone:775-829-7922
Practice Address - Fax:775-829-8202
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-28
Last Update Date:2014-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV16765183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV16765OtherPHARMACIST OF NEVADA LICENSE NUMBER