Provider Demographics
NPI:1508173683
Name:RAYNOLDS, KATHRYN AZZARA (RPH)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:AZZARA
Last Name:RAYNOLDS
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 1:5197 N CARPENTER RD
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:IL
Mailing Address - Zip Code:62515-7093
Mailing Address - Country:US
Mailing Address - Phone:217-364-5644
Mailing Address - Fax:217-364-5644
Practice Address - Street 1:5197 N CARPENTER RD
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:IL
Practice Address - Zip Code:62515-7093
Practice Address - Country:US
Practice Address - Phone:217-364-5644
Practice Address - Fax:217-364-5644
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-10
Last Update Date:2010-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051031757183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist