Provider Demographics
NPI:1053455758
Name:ROBERT W GRAY
Entity Type:Organization
Organization Name:ROBERT W GRAY
Other - Org Name:LYNCHBURG DRUG STORE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAY
Authorized Official - Suffix:
Authorized Official - Credentials:DPH
Authorized Official - Phone:931-759-7329
Mailing Address - Street 1:PO BOX 174
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:TN
Mailing Address - Zip Code:37352-0174
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:47 MECHANIC ST
Practice Address - Street 2:EASTSIDE PUBLIC SQUARE
Practice Address - City:LYNCHBURG
Practice Address - State:TN
Practice Address - Zip Code:37352
Practice Address - Country:US
Practice Address - Phone:931-759-7329
Practice Address - Fax:931-759-4604
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-16
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 3336C0003X, 3336C0004X
TN0000000633333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
4424595OtherOTHER ID NUMBER-COMMERCIAL NUMBER
TN4424595Medicaid
4424595OtherOTHER ID NUMBER
1184660001Medicare NSC