Provider Demographics
NPI:1902519846
Name:BYANSI, REAGAN
Entity Type:Individual
Prefix:
First Name:REAGAN
Middle Name:
Last Name:BYANSI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4698 S BRON BRECK ST
Mailing Address - Street 2:
Mailing Address - City:HOLLADAY
Mailing Address - State:UT
Mailing Address - Zip Code:84117-6402
Mailing Address - Country:US
Mailing Address - Phone:385-230-8387
Mailing Address - Fax:
Practice Address - Street 1:4698 S BRON BRECK ST
Practice Address - Street 2:
Practice Address - City:HOLLADAY
Practice Address - State:UT
Practice Address - Zip Code:84117-6402
Practice Address - Country:US
Practice Address - Phone:385-230-8387
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-05
Last Update Date:2023-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11433569-1701183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Multi-Specialty