Provider Demographics
NPI:1073658910
Name:REILLY, KEVIN J (PHARMD)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:J
Last Name:REILLY
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:711 N 1ST ST
Mailing Address - Street 2:APT. C207
Mailing Address - City:ELDRIDGE
Mailing Address - State:IA
Mailing Address - Zip Code:52748-1287
Mailing Address - Country:US
Mailing Address - Phone:319-290-7605
Mailing Address - Fax:
Practice Address - Street 1:629 6TH AVE
Practice Address - Street 2:
Practice Address - City:DE WITT
Practice Address - State:IA
Practice Address - Zip Code:52742-1635
Practice Address - Country:US
Practice Address - Phone:563-659-5042
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA18854183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist