MEDICARE: DR. MATTHEW HODGE PHARMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	PS47011	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	PS47011	OTHER	FL	PHARMACIST LICENSE #

General Provider Information

NPI Number	:	1750983680
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MATTHEW HODGE PHARMD

Provider Business Mailing Address
First Line	:	4255 W NEW HAVEN AVE
Second Line	:
City	:	MELBOURNE
State	:	FL
Zip	:	32904-3317
Country	:	US
Telephone Number	:	321-768-0438
Fax Number	:	321-768-8084

Provider Business Practice Location Address
First Line	:	4255 W NEW HAVEN AVE
Second Line	:
City	:	MELBOURNE
State	:	FL
Zip	:	32904-3317
Country	:	US
Telephone Number	:	321-768-0438
Fax Number	:	321-768-8084

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/16/2020
Last Update Date	:	11/16/2020

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