Provider Demographics
NPI:1003568106
Name:REYNOLDS, ABIGAIL BNICOLE
Entity Type:Individual
Prefix:
First Name:ABIGAIL
Middle Name:BNICOLE
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ABIGAIL
Other - Middle Name:
Other - Last Name:NEWMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:513 BARNES AVE
Mailing Address - Street 2:
Mailing Address - City:ALVA
Mailing Address - State:OK
Mailing Address - Zip Code:73717-2229
Mailing Address - Country:US
Mailing Address - Phone:580-327-3332
Mailing Address - Fax:
Practice Address - Street 1:513 BARNES AVE
Practice Address - Street 2:
Practice Address - City:ALVA
Practice Address - State:OK
Practice Address - Zip Code:73717-2288
Practice Address - Country:US
Practice Address - Phone:580-327-7266
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-20
Last Update Date:2022-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK19760183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist