=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972640688
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KENNETH HODGE RPH
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/31/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2 E MAIN ST
-----------------------------------------------------
City | MENDHAM
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07945-1505
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-543-2525
-----------------------------------------------------
Fax | 973-543-2396
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 558 DRAKESTOWN RD
-----------------------------------------------------
City | FLANDERS
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07836-9637
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-584-1198
-----------------------------------------------------
Fax | 973-543-2396
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 28RI01373700
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------