Healthcare Provider Details

I. General information

NPI: 1780960682
Provider Name (Legal Business Name): RAE HODGE RPH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2011
Last Update Date: 10/24/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2102 NEZ PERCE DR
LEWISTON ID
83501-4116
US

IV. Provider business mailing address

711 VISTA AVE
LEWISTON ID
83501-4626
US

V. Phone/Fax

Practice location:
  • Phone: 208-743-4434
  • Fax: 208-743-9422
Mailing address:
  • Phone: 208-305-8119
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberP5082
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRPH-0008715
License Number StateOR
# 3
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPH00019210
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: