Provider Demographics
NPI:1023405248
Name:DODGE, MARSHA
Entity type:Individual
Prefix:
First Name:MARSHA
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 1:3010 LAMPLIGHTER LN
Mailing Address - Street 2:
Mailing Address - City:KOKOMO
Mailing Address - State:IN
Mailing Address - Zip Code:46902-8124
Mailing Address - Country:US
Mailing Address - Phone:765-437-7014
Mailing Address - Fax:
Practice Address - Street 1:3010 LAMPLIGHTER LN
Practice Address - Street 2:
Practice Address - City:KOKOMO
Practice Address - State:IN
Practice Address - Zip Code:46902-8124
Practice Address - Country:US
Practice Address - Phone:765-437-7014
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-26
Last Update Date:2016-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS016988183500000X
IN26015488A183500000X
HIPH-2899183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist