Provider Demographics
NPI:1568745701
Name:MCCRAY, SUSAN (RPH)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:MCCRAY
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6360 IBERG ROAD
Mailing Address - Street 2:
Mailing Address - City:BREESE
Mailing Address - State:IL
Mailing Address - Zip Code:62230
Mailing Address - Country:US
Mailing Address - Phone:618-651-1204
Mailing Address - Fax:
Practice Address - Street 1:110 WALNUT ST
Practice Address - Street 2:
Practice Address - City:HIGHLAND
Practice Address - State:IL
Practice Address - Zip Code:62249
Practice Address - Country:US
Practice Address - Phone:618-651-1204
Practice Address - Fax:618-651-1217
Is Sole Proprietor?:No
Enumeration Date:2011-09-23
Last Update Date:2011-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051288044183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist