Provider Demographics
NPI:1972935849
Name:HODGES, MYRON KEITH
Entity Type:Individual
Prefix:
First Name:MYRON
Middle Name:KEITH
Last Name:HODGES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7453 HARGETT BLVD
Mailing Address - Street 2:
Mailing Address - City:GLOUCESTER
Mailing Address - State:VA
Mailing Address - Zip Code:23061-2038
Mailing Address - Country:US
Mailing Address - Phone:804-694-5815
Mailing Address - Fax:804-695-0216
Practice Address - Street 1:7453 HARGETT BLVD
Practice Address - Street 2:
Practice Address - City:GLOUCESTER
Practice Address - State:VA
Practice Address - Zip Code:23061-2038
Practice Address - Country:US
Practice Address - Phone:804-694-5815
Practice Address - Fax:804-695-0216
Is Sole Proprietor?:No
Enumeration Date:2013-08-02
Last Update Date:2013-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202009727183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist