Provider Demographics
NPI:1336751668
Name:DODGE, ELLOUISE MILDRED (RPH)
Entity type:Individual
Prefix:
First Name:ELLOUISE
Middle Name:MILDRED
Last Name:DODGE
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 E PIONEER PKWY
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76010-5856
Mailing Address - Country:US
Mailing Address - Phone:817-277-4463
Mailing Address - Fax:817-795-6458
Practice Address - Street 1:901 E PIONEER PKWY
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76010-5856
Practice Address - Country:US
Practice Address - Phone:817-277-4463
Practice Address - Fax:817-795-6458
Is Sole Proprietor?:No
Enumeration Date:2020-08-18
Last Update Date:2020-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX429461835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist