Provider Demographics
NPI:1750446845
Name:REAVIS, JOHN WALLACE
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:WALLACE
Last Name:REAVIS
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 1:3319 18TH ST S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58104-6537
Mailing Address - Country:US
Mailing Address - Phone:701-232-7589
Mailing Address - Fax:
Practice Address - Street 1:1532 32ND AVE S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-5987
Practice Address - Country:US
Practice Address - Phone:701-280-1928
Practice Address - Fax:701-280-1402
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND3411183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist