Provider Demographics
NPI:1902895873
Name:REYNOLDS, GARTH KYLE (RPH)
Entity Type:Individual
Prefix:MR
First Name:GARTH
Middle Name:KYLE
Last Name:REYNOLDS
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 1:1837 S WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62704-4047
Mailing Address - Country:US
Mailing Address - Phone:217-522-7300
Mailing Address - Fax:217-522-7349
Practice Address - Street 1:204 W COOK ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62704-2526
Practice Address - Country:US
Practice Address - Phone:217-522-7300
Practice Address - Fax:217-522-7349
Is Sole Proprietor?:No
Enumeration Date:2005-10-13
Last Update Date:2013-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002028993183500000X
IL51288648183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist