Provider Demographics
NPI:1912639352
Name:REESE, RANDY W (RPH)
Entity type:Individual
Prefix:
First Name:RANDY
Middle Name:W
Last Name:REESE
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1003 WOLFRUM RD
Mailing Address - Street 2:
Mailing Address - City:WELDON SPRING
Mailing Address - State:MO
Mailing Address - Zip Code:63304-7625
Mailing Address - Country:US
Mailing Address - Phone:636-300-0158
Mailing Address - Fax:
Practice Address - Street 1:5 BAYBERRY LN
Practice Address - Street 2:
Practice Address - City:SAINT PETERS
Practice Address - State:MO
Practice Address - Zip Code:63376-2617
Practice Address - Country:US
Practice Address - Phone:131-427-7360
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-24
Last Update Date:2022-12-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO041986183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist