Provider Demographics
NPI:1619557949
Name:SMITH, REAGAN JOAN
Entity Type:Individual
Prefix:
First Name:REAGAN
Middle Name:JOAN
Last Name:SMITH
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 1:1303 CEDAR CHASE DR
Mailing Address - Street 2:
Mailing Address - City:LANESVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47136-0019
Mailing Address - Country:US
Mailing Address - Phone:502-396-8883
Mailing Address - Fax:
Practice Address - Street 1:200 LAFOLLETTE STA S
Practice Address - Street 2:
Practice Address - City:FLOYDS KNOBS
Practice Address - State:IN
Practice Address - Zip Code:47119-9776
Practice Address - Country:US
Practice Address - Phone:812-923-0412
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-12
Last Update Date:2021-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN67036258A183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician