=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689046914
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NICOLE REED
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/26/2015
-----------------------------------------------------
Last Update Date | 02/11/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 626 W FRONT ST
-----------------------------------------------------
City | TRAVERSE CITY
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49684-2210
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 231-935-0185
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 626 W FRONT ST
-----------------------------------------------------
City | TRAVERSE CITY
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49684-2210
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 231-935-0185
-----------------------------------------------------
Fax | 231-935-1684
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 5315106642
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 61284
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------