Provider Demographics
NPI:1073082756
Name:GRAY, CASEY
Entity Type:Individual
Prefix:
First Name:CASEY
Middle Name:
Last Name:GRAY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:906 E OLIVE ST
Mailing Address - Street 2:
Mailing Address - City:LAMAR
Mailing Address - State:CO
Mailing Address - Zip Code:81052-2966
Mailing Address - Country:US
Mailing Address - Phone:719-336-0880
Mailing Address - Fax:
Practice Address - Street 1:906 E OLIVE ST
Practice Address - Street 2:
Practice Address - City:LAMAR
Practice Address - State:CO
Practice Address - Zip Code:81052-2966
Practice Address - Country:US
Practice Address - Phone:719-336-0880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-25
Last Update Date:2018-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0022509183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist