Provider Demographics
NPI:1336443522
Name:REYNOLDS, MARCIA GRAVITT (RPH)
Entity Type:Individual
Prefix:MRS
First Name:MARCIA
Middle Name:GRAVITT
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:240 SPARTA RD
Mailing Address - Street 2:
Mailing Address - City:NORTH WILKESBORO
Mailing Address - State:NC
Mailing Address - Zip Code:28659-3122
Mailing Address - Country:US
Mailing Address - Phone:336-667-0900
Mailing Address - Fax:336-667-5884
Practice Address - Street 1:240 SPARTA RD
Practice Address - Street 2:
Practice Address - City:NORTH WILKESBORO
Practice Address - State:NC
Practice Address - Zip Code:28659-3122
Practice Address - Country:US
Practice Address - Phone:336-667-0900
Practice Address - Fax:336-667-5884
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-02
Last Update Date:2011-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC10372183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist