Provider Demographics
NPI:1952774481
Name:DODGE, SAMANTHA (PHARM D)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:DODGE
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:490 N 2ND E
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:ID
Mailing Address - Zip Code:83647-2729
Mailing Address - Country:US
Mailing Address - Phone:208-587-3346
Mailing Address - Fax:
Practice Address - Street 1:490 N 2ND E
Practice Address - Street 2:
Practice Address - City:MOUNTAIN HOME
Practice Address - State:ID
Practice Address - Zip Code:83647-2729
Practice Address - Country:US
Practice Address - Phone:208-587-3346
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-05
Last Update Date:2015-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP7283183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist