Provider Demographics
NPI:1659411494
Name:GRAY, ROBERT W (DPH)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:W
Last Name:GRAY
Suffix:
Gender:M
Credentials:DPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 S MECHANIC ST
Mailing Address - Street 2:P.O. BOX 174
Mailing Address - City:LYNCHBURG
Mailing Address - State:TN
Mailing Address - Zip Code:37352-8353
Mailing Address - Country:US
Mailing Address - Phone:931-759-7329
Mailing Address - Fax:931-759-4604
Practice Address - Street 1:45 S MECHANIC ST
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:TN
Practice Address - Zip Code:37352-8353
Practice Address - Country:US
Practice Address - Phone:931-759-7329
Practice Address - Fax:931-759-4604
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN005858183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4424595Medicaid
TN4424595OtherNCPDP
TN1454364OtherTN MEDICAL ASSISTANCE
TN1454364OtherTN MEDICAL ASSISTANCE