Provider Demographics
NPI:1053397158
Name:BRAY, JACKSON M (RPH)
Entity type:Individual
Prefix:MR
First Name:JACKSON
Middle Name:M
Last Name:BRAY
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:327 WASH RD
Mailing Address - Street 2:
Mailing Address - City:FRANKFORT
Mailing Address - State:KY
Mailing Address - Zip Code:40601-8958
Mailing Address - Country:US
Mailing Address - Phone:502-223-2827
Mailing Address - Fax:502-227-2026
Practice Address - Street 1:662 E MAIN ST
Practice Address - Street 2:
Practice Address - City:FRANKFORT
Practice Address - State:KY
Practice Address - Zip Code:40601-2338
Practice Address - Country:US
Practice Address - Phone:502-223-2827
Practice Address - Fax:502-227-2026
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY007475183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY007475OtherPHARMACIST LICENSE