Healthcare Provider Details

I. General information

NPI: 1811989809
Provider Name (Legal Business Name): VIRGINIA M. KODACK RPH PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 08/17/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 STURBRIDGE RD
BRANCHBURG NJ
08853-4013
US

IV. Provider business mailing address

100 STURBRIDGE RD
BRANCHBURG NJ
08853-4013
US

V. Phone/Fax

Practice location:
  • Phone: 908-369-6403
  • Fax:
Mailing address:
  • Phone: 908-369-6403
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberR17540
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRP027706L
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number29233
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: