Provider Demographics
NPI:1093354615
Name:MODLIN, ALICIA (RPH)
Entity Type:Individual
Prefix:
First Name:ALICIA
Middle Name:
Last Name:MODLIN
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1541 SE 3RD ST STE 100
Mailing Address - Street 2:
Mailing Address - City:GRIMES
Mailing Address - State:IA
Mailing Address - Zip Code:50111-8878
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1541 SE 3RD ST STE 100
Practice Address - Street 2:
Practice Address - City:GRIMES
Practice Address - State:IA
Practice Address - Zip Code:50111-8878
Practice Address - Country:US
Practice Address - Phone:515-986-4527
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-30
Last Update Date:2019-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA18350183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist