Provider Demographics
NPI:1760793376
Name:REYNOLDS, JERRY DEAN (RPH)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:DEAN
Last Name:REYNOLDS
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 1:7127 REVERE CIR
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37421-5206
Mailing Address - Country:US
Mailing Address - Phone:423-899-0701
Mailing Address - Fax:
Practice Address - Street 1:5478 HIGHWAY 153
Practice Address - Street 2:
Practice Address - City:HIXSON
Practice Address - State:TN
Practice Address - Zip Code:37343-3782
Practice Address - Country:US
Practice Address - Phone:423-875-0855
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-29
Last Update Date:2010-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1080183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist