Provider Demographics
NPI:1497107833
Name:REYNOLDS, MOLLY (RPH)
Entity Type:Individual
Prefix:
First Name:MOLLY
Middle Name:
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:621 E LAKE ST
Mailing Address - Street 2:
Mailing Address - City:TAWAS CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48763-9213
Mailing Address - Country:US
Mailing Address - Phone:989-984-0924
Mailing Address - Fax:989-984-0928
Practice Address - Street 1:621 E LAKE ST
Practice Address - Street 2:
Practice Address - City:TAWAS CITY
Practice Address - State:MI
Practice Address - Zip Code:48763-9213
Practice Address - Country:US
Practice Address - Phone:989-984-0924
Practice Address - Fax:989-984-0928
Is Sole Proprietor?:No
Enumeration Date:2016-07-11
Last Update Date:2016-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302024960183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5302024960OtherSTATE OF MICHIGAN