Provider Demographics
NPI:1275701807
Name:REILLY, GARY WILLIAM (RPH)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:WILLIAM
Last Name:REILLY
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:840 COTTMAN AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19111-3017
Mailing Address - Country:US
Mailing Address - Phone:215-342-8740
Mailing Address - Fax:215-342-4607
Practice Address - Street 1:840 COTTMAN AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19111-3017
Practice Address - Country:US
Practice Address - Phone:215-342-8740
Practice Address - Fax:215-342-4607
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-18
Last Update Date:2008-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP029143L183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PARP029143LOtherPA STATE LICENSE NUMBER