Provider Demographics
NPI:1295831055
Name:REAVIS, MISTY DAWN (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:MISTY
Middle Name:DAWN
Last Name:REAVIS
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 BATTLEGROUND AVE STE C
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27408-4030
Mailing Address - Country:US
Mailing Address - Phone:336-286-0074
Mailing Address - Fax:
Practice Address - Street 1:2500 BATTLEGROUND AVE STE C
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27408-4030
Practice Address - Country:US
Practice Address - Phone:336-286-0074
Practice Address - Fax:336-286-6696
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC15909183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0417922Medicaid