Provider Demographics
NPI:1154601771
Name:REYNOLDS, FREDERICK ALLEN (PHARMACIST)
Entity type:Individual
Prefix:
First Name:FREDERICK
Middle Name:ALLEN
Last Name:REYNOLDS
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:711 DEVONSHIRE DR
Mailing Address - Street 2:
Mailing Address - City:STURGIS
Mailing Address - State:MI
Mailing Address - Zip Code:49091-9009
Mailing Address - Country:US
Mailing Address - Phone:269-651-8674
Mailing Address - Fax:
Practice Address - Street 1:950 S CENTERVILLE RD
Practice Address - Street 2:
Practice Address - City:STURGIS
Practice Address - State:MI
Practice Address - Zip Code:49091-2089
Practice Address - Country:US
Practice Address - Phone:269-651-9519
Practice Address - Fax:269-651-9548
Is Sole Proprietor?:No
Enumeration Date:2011-08-26
Last Update Date:2011-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302020198183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist