Provider Demographics
NPI:1154807188
Name:GRAY, GAIL LYNNE
Entity type:Individual
Prefix:
First Name:GAIL
Middle Name:LYNNE
Last Name:GRAY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 COVERED BRIDGE LN
Mailing Address - Street 2:
Mailing Address - City:GLEN CARBON
Mailing Address - State:IL
Mailing Address - Zip Code:62034-1494
Mailing Address - Country:US
Mailing Address - Phone:618-604-2567
Mailing Address - Fax:
Practice Address - Street 1:11420 LACKLAND RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63146-3559
Practice Address - Country:US
Practice Address - Phone:314-994-9900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-12
Last Update Date:2018-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.040756183500000X
MO042225183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist