Provider Demographics
NPI:1790388411
Name:WRAY, REGINA E
Entity Type:Individual
Prefix:
First Name:REGINA
Middle Name:E
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 1:170 COOK AVE
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24019-8631
Mailing Address - Country:US
Mailing Address - Phone:540-815-8338
Mailing Address - Fax:
Practice Address - Street 1:4524 CHALLENGER AVE
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24012-7028
Practice Address - Country:US
Practice Address - Phone:540-977-4881
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-17
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202010379183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist