Provider Demographics
NPI:1295381564
Name:HODGES, LANE MADISON (PHARMD)
Entity Type:Individual
Prefix:
First Name:LANE
Middle Name:MADISON
Last Name:HODGES
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2051 BLYTHEWOOD CROSSING LN APT 622
Mailing Address - Street 2:
Mailing Address - City:BLYTHEWOOD
Mailing Address - State:SC
Mailing Address - Zip Code:29016-7158
Mailing Address - Country:US
Mailing Address - Phone:864-238-9137
Mailing Address - Fax:
Practice Address - Street 1:616 S WALNUT ST.
Practice Address - Street 2:
Practice Address - City:PAMPLICO
Practice Address - State:SC
Practice Address - Zip Code:29583
Practice Address - Country:US
Practice Address - Phone:843-493-2311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-13
Last Update Date:2019-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC42106183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist