Provider Demographics
NPI:1881161610
Name:REIS, LARRY ROBERT (RPH)
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:ROBERT
Last Name:REIS
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 1:551 WRANGLER ST
Mailing Address - Street 2:
Mailing Address - City:OAKDALE
Mailing Address - State:CA
Mailing Address - Zip Code:95361-8252
Mailing Address - Country:US
Mailing Address - Phone:559-301-2020
Mailing Address - Fax:559-272-2124
Practice Address - Street 1:551 WRANGLER ST
Practice Address - Street 2:
Practice Address - City:OAKDALE
Practice Address - State:CA
Practice Address - Zip Code:95361-8252
Practice Address - Country:US
Practice Address - Phone:559-301-2020
Practice Address - Fax:559-272-2124
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-30
Last Update Date:2018-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA271141835G0303X, 183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No1835G0303XPharmacy Service ProvidersPharmacistGeriatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA27114OtherPHARMACY LICENSE