Provider Demographics
NPI:1851328751
Name:REILLY PHARMACY LLC
Entity Type:Organization
Organization Name:REILLY PHARMACY LLC
Other - Org Name:MEDICAP PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:VINCENT
Authorized Official - Middle Name:GERARD
Authorized Official - Last Name:REILLY
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:605-368-5333
Mailing Address - Street 1:PO BOX 487
Mailing Address - Street 2:
Mailing Address - City:TEA
Mailing Address - State:SD
Mailing Address - Zip Code:57064-0487
Mailing Address - Country:US
Mailing Address - Phone:605-368-5333
Mailing Address - Fax:605-368-5337
Practice Address - Street 1:720 E. FIRST STREET
Practice Address - Street 2:
Practice Address - City:TEA
Practice Address - State:SD
Practice Address - Zip Code:57064-0487
Practice Address - Country:US
Practice Address - Phone:605-368-5333
Practice Address - Fax:605-368-5337
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-27
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD100-18693336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD8504242Medicaid
SD4353710OtherNCPDP #
SD4353710OtherNCPDP #
SDBM9189374OtherDEA #
SD5440870001Medicare NSC