Provider Demographics
NPI:1568827749
Name:GRAY, SHANNON K (RPH,CDE)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:K
Last Name:GRAY
Suffix:
Gender:F
Credentials:RPH,CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1594 FREEDOM BLVD
Mailing Address - Street 2:SUITE 102 B
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29505-6046
Mailing Address - Country:US
Mailing Address - Phone:843-674-2700
Mailing Address - Fax:843-674-2729
Practice Address - Street 1:1594 FREEDOM BLVD
Practice Address - Street 2:SUITE 102 B
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29505-6046
Practice Address - Country:US
Practice Address - Phone:843-674-2700
Practice Address - Fax:843-674-2729
Is Sole Proprietor?:No
Enumeration Date:2015-12-15
Last Update Date:2015-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC21410166174H00000X
SC9108183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator
No183500000XPharmacy Service ProvidersPharmacist