Provider Demographics
NPI:1447918511
Name:RAY, JESSIE LEOTA
Entity type:Individual
Prefix:
First Name:JESSIE
Middle Name:LEOTA
Last Name:RAY
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 1:1750 E BROADWAY RD
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85282-1612
Mailing Address - Country:US
Mailing Address - Phone:480-557-0970
Mailing Address - Fax:
Practice Address - Street 1:1750 E BROADWAY RD
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85282-1612
Practice Address - Country:US
Practice Address - Phone:480-557-0970
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-06
Last Update Date:2021-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS025644183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist