Provider Demographics
NPI:1497915433
Name:RAY, GARY WENDELL (R PH)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:WENDELL
Last Name:RAY
Suffix:
Gender:M
Credentials:R PH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2505 S CARRIER PKWY
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75052-5017
Mailing Address - Country:US
Mailing Address - Phone:972-264-0268
Mailing Address - Fax:972-262-1750
Practice Address - Street 1:2505 S CARRIER PKWY
Practice Address - Street 2:
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75052-5017
Practice Address - Country:US
Practice Address - Phone:972-264-0268
Practice Address - Fax:972-262-1750
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-12
Last Update Date:2019-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX141836Medicaid