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General NPI Number Information
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NPI Number | 1730565003
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Entity Type | Individual
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Provider Name | GARY RAYNOLDS RPH, B.S. PHARM
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Gender | Male
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Dates
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Enumeration Date | 08/10/2015
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Last Update Date | 08/10/2015
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Provider Practice Location Address
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Address Line | 2115 S MACARTHUR BLVD
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City | SPRINGFIELD
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State | IL
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Zip | 62704-4501
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Country | US
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Telephone | 217-726-1003
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Fax |
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Provider Business Mailing Address
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Address Line | 5197 N CARPENTER RD
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City | BUFFALO
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State | IL
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Zip | 62515-7093
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Country | US
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Telephone | 217-415-1764
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Fax | 217-364-5644
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | 051034225
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | 008653
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License Number State | KY
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