Provider Demographics
NPI:1679919161
Name:GRAY, ALAN D (RPH)
Entity type:Individual
Prefix:
First Name:ALAN
Middle Name:D
Last Name:GRAY
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 1:13308 HOLLOWBEND LN
Mailing Address - Street 2:
Mailing Address - City:RIVERVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:33569-5759
Mailing Address - Country:US
Mailing Address - Phone:813-758-0981
Mailing Address - Fax:813-409-3535
Practice Address - Street 1:1510 US HIGHWAY 17 N
Practice Address - Street 2:
Practice Address - City:WAUCHULA
Practice Address - State:FL
Practice Address - Zip Code:33873-5002
Practice Address - Country:US
Practice Address - Phone:863-767-1062
Practice Address - Fax:863-773-3789
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-11
Last Update Date:2013-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS23115183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist