Provider Demographics
NPI:1558951194
Name:REILLY, MARY ELAINE
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ELAINE
Last Name:REILLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23088 WOODEND RD
Mailing Address - Street 2:
Mailing Address - City:TONGANOXIE
Mailing Address - State:KS
Mailing Address - Zip Code:66086-3327
Mailing Address - Country:US
Mailing Address - Phone:913-634-0553
Mailing Address - Fax:
Practice Address - Street 1:15415 PINEHURST DR
Practice Address - Street 2:
Practice Address - City:BASEHOR
Practice Address - State:KS
Practice Address - Zip Code:66007-8237
Practice Address - Country:US
Practice Address - Phone:913-724-3666
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-18
Last Update Date:2021-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS11836183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist