Provider Demographics
NPI:1164041893
Name:RAY, IAN JAMESON
Entity Type:Individual
Prefix:
First Name:IAN
Middle Name:JAMESON
Last Name:RAY
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 1:5960 RICHMOND LN
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46254-1067
Mailing Address - Country:US
Mailing Address - Phone:317-361-7530
Mailing Address - Fax:
Practice Address - Street 1:5555 MICHIGAN RD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46228-2219
Practice Address - Country:US
Practice Address - Phone:317-287-0427
Practice Address - Fax:317-287-0427
Is Sole Proprietor?:No
Enumeration Date:2020-04-13
Last Update Date:2020-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26026693A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist