Healthcare Provider Details

I. General information

NPI: 1275593410
Provider Name (Legal Business Name): FT REYNOLDS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/23/2006
Last Update Date: 07/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1014 W BELL ST
GLENDIVE MT
59330-1502
US

IV. Provider business mailing address

1014 W BELL ST
GLENDIVE MT
59330-1502
US

V. Phone/Fax

Practice location:
  • Phone: 406-377-4920
  • Fax:
Mailing address:
  • Phone: 406-377-4920
  • Fax: 406-377-4921

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number1285
License Number StateMT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier2701084
Identifier TypeOTHER
Identifier State
Identifier IssuerNCPDP PROVIDER IDENTIFICATION NUMBER

VIII. Authorized Official

Name: WILLIAM DOUGLAS WALLEY
Title or Position: VICE PRESIDENT
Credential:
Phone: 406-852-0406