=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003334590
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PRISCILLA REYNOLDS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/05/2017
-----------------------------------------------------
Last Update Date | 09/05/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 955 N WHITE SANDS BLVD
-----------------------------------------------------
City | ALAMOGORDO
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 88310-6925
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 575-434-4116
-----------------------------------------------------
Fax | 575-434-4116
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 955 N WHITE SANDS BLVD
-----------------------------------------------------
City | ALAMOGORDO
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 88310
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 575-434-4116
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | RP00008795
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------