Provider Demographics
NPI:1922013564
Name:REYNOLDS PHARMACY INC
Entity Type:Organization
Organization Name:REYNOLDS PHARMACY INC
Other - Org Name:DOCTORS CUSTOM COMPOUNDING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAN
Authorized Official - Middle Name:
Authorized Official - Last Name:REYNOLDS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-473-3444
Mailing Address - Street 1:162 W MAIN ST
Mailing Address - Street 2:STE K
Mailing Address - City:WHITEWATER
Mailing Address - State:WI
Mailing Address - Zip Code:53190-1995
Mailing Address - Country:US
Mailing Address - Phone:262-473-3444
Mailing Address - Fax:262-473-3444
Practice Address - Street 1:162 W MAIN ST STE K
Practice Address - Street 2:
Practice Address - City:WHITEWATER
Practice Address - State:WI
Practice Address - Zip Code:53190-1995
Practice Address - Country:US
Practice Address - Phone:262-473-3444
Practice Address - Fax:262-473-3444
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2014-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
WI9277-423336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2114604OtherPK
WI33061500Medicaid
2114604OtherPK