=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588145437
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KATRINA REYNOLDS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/28/2018
-----------------------------------------------------
Last Update Date | 08/28/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1680 FORT CAMPBELL BLVD
-----------------------------------------------------
City | CLARKSVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37042-3537
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 931-552-0348
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12300 CANNONBALL RD
-----------------------------------------------------
City | FAIRFAX
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22030-6530
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 256-783-9542
-----------------------------------------------------
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 | 14829
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 43736
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | RPH022500
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 33562
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------