Provider Demographics
NPI:1154603314
Name:DODD, BOBBY
Entity type:Individual
Prefix:
First Name:BOBBY
Middle Name:
Last Name:DODD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4502 SUZANNE AVE
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75503-0403
Mailing Address - Country:US
Mailing Address - Phone:903-832-9989
Mailing Address - Fax:870-642-8357
Practice Address - Street 1:808 W COLLIN RAYE DR
Practice Address - Street 2:
Practice Address - City:DE QUEEN
Practice Address - State:AR
Practice Address - Zip Code:71832-2022
Practice Address - Country:US
Practice Address - Phone:870-642-8021
Practice Address - Fax:870-642-8357
Is Sole Proprietor?:No
Enumeration Date:2011-09-14
Last Update Date:2011-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPD06130183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist