Provider Demographics
NPI:1659081347
Name:GRAY, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
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 1:261 LEVITICUS DR
Mailing Address - Street 2:
Mailing Address - City:BUNKER HILL
Mailing Address - State:WV
Mailing Address - Zip Code:25413-3597
Mailing Address - Country:US
Mailing Address - Phone:540-429-5230
Mailing Address - Fax:
Practice Address - Street 1:11116 MEDICAL CAMPUS RD
Practice Address - Street 2:
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21742-6710
Practice Address - Country:US
Practice Address - Phone:301-790-8000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-02
Last Update Date:2022-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202218054183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist