1598114365 NPI number — MRS. AUTUMN AMBER REARDON PHARMD, RPH

Table of content: TIFFANY LEE (NPI 1679181697)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598114365 NPI number — MRS. AUTUMN AMBER REARDON PHARMD, RPH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
REARDON
Provider First Name:
AUTUMN
Provider Middle Name:
AMBER
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PHARMD, RPH
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WOLF
Provider Other First Name:
AUTUMN
Provider Other Middle Name:
AMBER
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PHARMD, RPH
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1598114365
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/03/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1415 CURRAN HWY
Provider Second Line Business Mailing Address:
PHARMACY DEPT
Provider Business Mailing Address City Name:
NORTH ADAMS
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01247
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
413-664-4040
Provider Business Mailing Address Fax Number:
413-664-7576

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1415 CURRAN HWY
Provider Second Line Business Practice Location Address:
PHARMACY DEPT
Provider Business Practice Location Address City Name:
NORTH ADAMS
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01247
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
413-664-4040
Provider Business Practice Location Address Fax Number:
413-664-7576
Provider Enumeration Date:
06/12/2016

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1835G0303X , with the licence number:  PH236062 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 183500000X , with the licence number: PH236062 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)