Provider Demographics
NPI:1477504033
Name:GRAY PHARM INC
Entity Type:Organization
Organization Name:GRAY PHARM INC
Other - Org Name:MEDICINE SHOPPE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:A
Authorized Official - Last Name:GRAYSON
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:318-323-2883
Mailing Address - Street 1:1510 S 2ND ST
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71202-2742
Mailing Address - Country:US
Mailing Address - Phone:318-323-2883
Mailing Address - Fax:318-323-8732
Practice Address - Street 1:1510 S 2ND ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71202-2742
Practice Address - Country:US
Practice Address - Phone:318-323-2883
Practice Address - Fax:318-323-8732
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-16
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA2609-IR333600000X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1924489OtherNCPDP #
LA1260657Medicaid
LA1260657Medicaid
LABT2990869OtherDEA #
LA5DH88Medicare PIN