Provider Demographics
NPI:1871577213
Name:GRAY, JENNIFER MARIE (RPH)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MARIE
Last Name:GRAY
Suffix:
Gender:F
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:PO BOX 7454
Mailing Address - Street 2:
Mailing Address - City:BONNEY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:98391-0948
Mailing Address - Country:US
Mailing Address - Phone:253-891-0646
Mailing Address - Fax:
Practice Address - Street 1:12946 SE KENT KANGLEY RD
Practice Address - Street 2:
Practice Address - City:KENT
Practice Address - State:WA
Practice Address - Zip Code:98030-7940
Practice Address - Country:US
Practice Address - Phone:253-631-6874
Practice Address - Fax:253-631-7131
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH00019102183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist