Provider Demographics
NPI:1982377313
Name:REILLY, NINA KRISTINE
Entity type:Individual
Prefix:
First Name:NINA
Middle Name:KRISTINE
Last Name:REILLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 WORCESTER RD
Mailing Address - Street 2:
Mailing Address - City:WEBSTER
Mailing Address - State:MA
Mailing Address - Zip Code:01570-1652
Mailing Address - Country:US
Mailing Address - Phone:508-949-8804
Mailing Address - Fax:866-301-5281
Practice Address - Street 1:2 WORCESTER RD
Practice Address - Street 2:
Practice Address - City:WEBSTER
Practice Address - State:MA
Practice Address - Zip Code:01570-1652
Practice Address - Country:US
Practice Address - Phone:508-949-8804
Practice Address - Fax:866-301-5281
Is Sole Proprietor?:No
Enumeration Date:2021-07-30
Last Update Date:2021-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA23032183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2021Medicaid