Provider Demographics
NPI:1982682878
Name:RAY, TREVOR VANCE (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:TREVOR
Middle Name:VANCE
Last Name:RAY
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:908 WALLACE AVE
Mailing Address - Street 2:SUITE 105
Mailing Address - City:LEITCHFIELD
Mailing Address - State:KY
Mailing Address - Zip Code:42754-1479
Mailing Address - Country:US
Mailing Address - Phone:270-259-8500
Mailing Address - Fax:270-230-8517
Practice Address - Street 1:908 WALLACE AVE
Practice Address - Street 2:SUITE 105
Practice Address - City:LEITCHFIELD
Practice Address - State:KY
Practice Address - Zip Code:42754-1479
Practice Address - Country:US
Practice Address - Phone:270-259-8500
Practice Address - Fax:270-230-8517
Is Sole Proprietor?:No
Enumeration Date:2006-01-03
Last Update Date:2011-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY012012183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY012012OtherKENTUCKY STATE LICENSE
KY0682670001Medicare NSC