Provider Demographics
NPI:1720378995
Name:REYNOLDS, KERRY BRIAN
Entity Type:Individual
Prefix:MR
First Name:KERRY
Middle Name:BRIAN
Last Name:REYNOLDS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2006 N SAGINAW RD
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48640-6614
Mailing Address - Country:US
Mailing Address - Phone:989-631-4321
Mailing Address - Fax:
Practice Address - Street 1:2006 N SAGINAW RD
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:MI
Practice Address - Zip Code:48640-6614
Practice Address - Country:US
Practice Address - Phone:989-631-4321
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-08
Last Update Date:2011-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302026137183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist