Provider Demographics
NPI:1023323425
Name:BODINE, ROBERT JAY (RPH)
Entity type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:JAY
Last Name:BODINE
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:165 BRANDON RD
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:NJ
Mailing Address - Zip Code:08759-6244
Mailing Address - Country:US
Mailing Address - Phone:732-657-1989
Mailing Address - Fax:
Practice Address - Street 1:19 UNION AVE
Practice Address - Street 2:
Practice Address - City:LAKEHURST
Practice Address - State:NJ
Practice Address - Zip Code:08733-3023
Practice Address - Country:US
Practice Address - Phone:732-657-6521
Practice Address - Fax:732-657-1625
Is Sole Proprietor?:No
Enumeration Date:2010-08-11
Last Update Date:2010-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI01581700183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6720102Medicaid