Provider Demographics
NPI:1285816942
Name:HODGE, KRISTYN (RPH)
Entity Type:Individual
Prefix:
First Name:KRISTYN
Middle Name:
Last Name:HODGE
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 1:9543 BREWERTON RD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:BREWERTON
Mailing Address - State:NY
Mailing Address - Zip Code:13029-9426
Mailing Address - Country:US
Mailing Address - Phone:315-676-3676
Mailing Address - Fax:
Practice Address - Street 1:9543 BREWERTON RD
Practice Address - Street 2:SUITE 1
Practice Address - City:BREWERTON
Practice Address - State:NY
Practice Address - Zip Code:13029-9426
Practice Address - Country:US
Practice Address - Phone:315-676-3676
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-04
Last Update Date:2007-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY050325183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist