Provider Demographics
NPI:1811989809
Name:KODACK, VIRGINIA M (RPH PHARMD)
Entity type:Individual
Prefix:DR
First Name:VIRGINIA
Middle Name:M
Last Name:KODACK
Suffix:
Gender:F
Credentials:RPH PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 STURBRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:BRANCHBURG
Mailing Address - State:NJ
Mailing Address - Zip Code:08853-4013
Mailing Address - Country:US
Mailing Address - Phone:908-369-6403
Mailing Address - Fax:
Practice Address - Street 1:100 STURBRIDGE RD
Practice Address - Street 2:
Practice Address - City:BRANCHBURG
Practice Address - State:NJ
Practice Address - Zip Code:08853-4013
Practice Address - Country:US
Practice Address - Phone:908-369-6403
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJR17540183500000X
PARP027706L183500000X
CA29233183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist