Provider Demographics
NPI:1275593410
Name:FT REYNOLDS
Entity Type:Organization
Organization Name:FT REYNOLDS
Other - Org Name:F & G PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:DOUGLAS
Authorized Official - Last Name:WALLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:406-852-0406
Mailing Address - Street 1:1014 W BELL ST
Mailing Address - Street 2:
Mailing Address - City:GLENDIVE
Mailing Address - State:MT
Mailing Address - Zip Code:59330-1502
Mailing Address - Country:US
Mailing Address - Phone:406-377-4920
Mailing Address - Fax:406-377-4921
Practice Address - Street 1:1014 W BELL ST
Practice Address - Street 2:
Practice Address - City:GLENDIVE
Practice Address - State:MT
Practice Address - Zip Code:59330-1502
Practice Address - Country:US
Practice Address - Phone:406-377-4920
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-23
Last Update Date:2019-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT12853336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2701084OtherNCPDP PROVIDER IDENTIFICATION NUMBER
MT0568880Medicaid
2701084OtherNCPDP PROVIDER IDENTIFICATION NUMBER
6312400001Medicare NSC
MT0568880Medicaid