MEDICARE: REYNOLDS PHARMACY INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	333600000X	Pharmacy
2	3336C0003X	Community/Retail Pharmacy	9277-42	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2114604	OTHER		PK
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1922013564
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	REYNOLDS PHARMACY INC

Provider Business Mailing Address
First Line	:	162 W MAIN ST
Second Line	:	STE K
City	:	WHITEWATER
State	:	WI
Zip	:	53190-1995
Country	:	US
Telephone Number	:	262-473-3444
Fax Number	:	262-473-3444

Provider Business Practice Location Address
First Line	:	162 W MAIN ST STE K
Second Line	:
City	:	WHITEWATER
State	:	WI
Zip	:	53190-1995
Country	:	US
Telephone Number	:	262-473-3444
Fax Number	:	262-473-3444

Authorized Official
Title or Position	:	PRESIDENT OWNER
Name	:	DAN REYNOLDS
Credential	:
Telephone Number	:	262-473-3444

Provider Enumeration Date	:	07/30/2006
Last Update Date	:	10/29/2014

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