Provider Demographics
NPI:1700831211
Name:REILLY, VINCENT GERARD (RPH)
Entity Type:Individual
Prefix:MR
First Name:VINCENT
Middle Name:GERARD
Last Name:REILLY
Suffix:
Gender:M
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:PO BOX 397
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:SD
Mailing Address - Zip Code:57033-0397
Mailing Address - Country:US
Mailing Address - Phone:605-528-2000
Mailing Address - Fax:605-528-2003
Practice Address - Street 1:304 W. HIGHWAY 38
Practice Address - Street 2:SUITE 102
Practice Address - City:HARTFORD
Practice Address - State:SD
Practice Address - Zip Code:57033-0397
Practice Address - Country:US
Practice Address - Phone:605-528-2000
Practice Address - Fax:605-528-2003
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD4455183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD4455OtherPHARMACIST LICENSE