Provider Demographics
NPI:1043330681
Name:REYNOLDS, CHAD MARION (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:CHAD
Middle Name:MARION
Last Name:REYNOLDS
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 WINDSOR AVE
Mailing Address - Street 2:
Mailing Address - City:GLASGOW
Mailing Address - State:KY
Mailing Address - Zip Code:42141-2256
Mailing Address - Country:US
Mailing Address - Phone:270-651-7627
Mailing Address - Fax:270-651-9261
Practice Address - Street 1:1220 N RACE ST
Practice Address - Street 2:
Practice Address - City:GLASGOW
Practice Address - State:KY
Practice Address - Zip Code:42141-3462
Practice Address - Country:US
Practice Address - Phone:270-651-7627
Practice Address - Fax:270-651-9261
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY011224183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY54025770Medicaid