Provider Demographics
NPI:1972993418
Name:GRAY, JEANETTE
Entity Type:Individual
Prefix:MRS
First Name:JEANETTE
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 1:3867 OLD FEDERAL HILL RD
Mailing Address - Street 2:
Mailing Address - City:JARRETTSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21084-1631
Mailing Address - Country:US
Mailing Address - Phone:443-243-7466
Mailing Address - Fax:
Practice Address - Street 1:580 MARKETPLACE DR
Practice Address - Street 2:
Practice Address - City:BEL AIR
Practice Address - State:MD
Practice Address - Zip Code:21014-4310
Practice Address - Country:US
Practice Address - Phone:410-638-9031
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-04
Last Update Date:2015-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDT05261183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician