=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033406129
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MRS. KELLENE KAY HODGES
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/08/2011
-----------------------------------------------------
Last Update Date | 07/08/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10 CROOKED RUN PLZ T-2297
-----------------------------------------------------
City | FRONT ROYAL
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22630-7004
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 540-631-3291
-----------------------------------------------------
Fax | 540-631-3400
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10 CROOKED RUN PLZ T-2297
-----------------------------------------------------
City | FRONT ROYAL
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22630-7004
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 540-631-3291
-----------------------------------------------------
Fax | 540-631-3400
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 0202207836
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------