Provider Demographics
NPI:1780960682
Name:HODGE, RAE (RPH)
Entity type:Individual
Prefix:
First Name:RAE
Middle Name:
Last Name: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 1:711 VISTA AVE
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-4626
Mailing Address - Country:US
Mailing Address - Phone:208-305-8119
Mailing Address - Fax:
Practice Address - Street 1:2102 NEZ PERCE DR
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-4116
Practice Address - Country:US
Practice Address - Phone:208-743-4434
Practice Address - Fax:208-743-9422
Is Sole Proprietor?:No
Enumeration Date:2011-10-24
Last Update Date:2011-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP5082183500000X
ORRPH-0008715183500000X
WAPH00019210183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist