Provider Demographics
NPI:1407433618
Name:GRAY, CAROL ANNE
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:ANNE
Last Name:GRAY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:427 W CARTER LN
Mailing Address - Street 2:
Mailing Address - City:HENDRIX
Mailing Address - State:OK
Mailing Address - Zip Code:74741-2518
Mailing Address - Country:US
Mailing Address - Phone:158-057-9174
Mailing Address - Fax:
Practice Address - Street 1:3712 W MAIN ST
Practice Address - Street 2:
Practice Address - City:DURANT
Practice Address - State:OK
Practice Address - Zip Code:74701-4529
Practice Address - Country:US
Practice Address - Phone:580-924-5112
Practice Address - Fax:580-924-4551
Is Sole Proprietor?:No
Enumeration Date:2021-03-24
Last Update Date:2021-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1097728183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician