Provider Demographics
NPI:1093252785
Name:REILLY, COLLEEN MARY
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:MARY
Last Name:REILLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8524 W 109TH TER
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66210-1654
Mailing Address - Country:US
Mailing Address - Phone:913-345-1978
Mailing Address - Fax:
Practice Address - Street 1:8524 W 109TH TER
Practice Address - Street 2:
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66210-1654
Practice Address - Country:US
Practice Address - Phone:913-345-1978
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-19
Last Update Date:2017-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO043408183500000X
KS1-12095183500000X
NE9668183500000X
AZ9756183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist