Provider Demographics
NPI:1902357882
Name:DODGE, EMILY
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:DODGE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:815 CANYON DEL REY BLVD
Mailing Address - Street 2:
Mailing Address - City:DEL REY OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:93940-5525
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:815 CANYON DEL REY BLVD
Practice Address - Street 2:
Practice Address - City:DEL REY OAKS
Practice Address - State:CA
Practice Address - Zip Code:93940-5525
Practice Address - Country:US
Practice Address - Phone:831-313-2104
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-17
Last Update Date:2016-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA75729183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist