Provider Demographics
NPI:1518446244
Name:JACKSON-HODGE, KIM INEZ (RPH)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:INEZ
Last Name:JACKSON-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 1:350 WALTERS RD
Mailing Address - Street 2:
Mailing Address - City:SUISUN CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94585-3043
Mailing Address - Country:US
Mailing Address - Phone:707-639-4982
Mailing Address - Fax:707-639-4983
Practice Address - Street 1:350 WALTERS RD
Practice Address - Street 2:
Practice Address - City:SUISUN CITY
Practice Address - State:CA
Practice Address - Zip Code:94585-3043
Practice Address - Country:US
Practice Address - Phone:707-639-4982
Practice Address - Fax:707-639-4983
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-13
Last Update Date:2018-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA40857183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist