Provider Demographics
NPI:1689845166
Name:GRAVITT, WAYNE (RPH)
Entity Type:Individual
Prefix:
First Name:WAYNE
Middle Name:
Last Name:GRAVITT
Suffix:
Gender:M
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:PO BOX 159
Mailing Address - Street 2:
Mailing Address - City:LACKEY
Mailing Address - State:KY
Mailing Address - Zip Code:41643-0159
Mailing Address - Country:US
Mailing Address - Phone:606-358-2661
Mailing Address - Fax:606-358-9215
Practice Address - Street 1:RT 550 MILLARD ALLEN DR
Practice Address - Street 2:
Practice Address - City:LACKEY
Practice Address - State:KY
Practice Address - Zip Code:41643
Practice Address - Country:US
Practice Address - Phone:606-358-2661
Practice Address - Fax:606-358-9215
Is Sole Proprietor?:No
Enumeration Date:2008-03-12
Last Update Date:2008-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY007828183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist