Provider Demographics
NPI:1710517784
Name:WRAY, FONDA
Entity Type:Individual
Prefix:
First Name:FONDA
Middle Name:
Last Name:WRAY
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 1:7116 ROSE QUARTZ CT
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76132-4331
Mailing Address - Country:US
Mailing Address - Phone:317-450-0784
Mailing Address - Fax:
Practice Address - Street 1:2210 S FIELDER RD
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76013-6258
Practice Address - Country:US
Practice Address - Phone:817-277-3533
Practice Address - Fax:817-277-7496
Is Sole Proprietor?:No
Enumeration Date:2020-01-18
Last Update Date:2020-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX564961835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist