=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528663770
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | THERESA REID
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/03/2020
-----------------------------------------------------
Last Update Date | 12/03/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 50980 NORTH AVE
-----------------------------------------------------
City | MACOMB
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48042-4626
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-949-7323
-----------------------------------------------------
Fax | 586-949-7345
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 50980 NORTH AVE
-----------------------------------------------------
City | MACOMB
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48042-4626
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-949-7323
-----------------------------------------------------
Fax | 586-949-7345
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 5302030437
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------