Provider Demographics
NPI:1174734792
Name:HODGES, SHELLY GAIL
Entity type:Individual
Prefix:MRS
First Name:SHELLY
Middle Name:GAIL
Last Name:HODGES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 WINDSONG WAY
Mailing Address - Street 2:
Mailing Address - City:NITRO
Mailing Address - State:WV
Mailing Address - Zip Code:25143-1138
Mailing Address - Country:US
Mailing Address - Phone:304-776-5329
Mailing Address - Fax:304-204-2223
Practice Address - Street 1:106 21ST ST
Practice Address - Street 2:
Practice Address - City:NITRO
Practice Address - State:WV
Practice Address - Zip Code:25143-1740
Practice Address - Country:US
Practice Address - Phone:304-755-0128
Practice Address - Fax:304-204-2223
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV5122183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist