Healthcare Provider Details

I. General information

NPI: 1164962130
Provider Name (Legal Business Name): JESSICA NICOLE REILLY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/24/2017
Last Update Date: 03/27/2026
Certification Date: 03/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4575 E BROADWAY BLVD
TUCSON AZ
85711-3509
US

IV. Provider business mailing address

2045 E JUANITA ST
TUCSON AZ
85719-3816
US

V. Phone/Fax

Practice location:
  • Phone: 520-375-9111
  • Fax:
Mailing address:
  • Phone: 520-906-7381
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberS022511
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number76306
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: