Provider Demographics
NPI:1487261434
Name:HODGES, VAN (PHARMD)
Entity type:Individual
Prefix:
First Name:VAN
Middle Name:
Last Name:HODGES
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 E 7TH AVE
Mailing Address - Street 2:
Mailing Address - City:BRISTOW
Mailing Address - State:OK
Mailing Address - Zip Code:74010-2503
Mailing Address - Country:US
Mailing Address - Phone:918-367-3328
Mailing Address - Fax:918-367-2415
Practice Address - Street 1:201 E 7TH AVE
Practice Address - Street 2:
Practice Address - City:BRISTOW
Practice Address - State:OK
Practice Address - Zip Code:74010-2503
Practice Address - Country:US
Practice Address - Phone:918-367-3328
Practice Address - Fax:918-367-2415
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-24
Last Update Date:2020-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK16130183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100236210AMedicaid