Provider Demographics
NPI:1295346955
Name:RAY, DANIEL (PHARMD)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:
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 1:104 N LOMBARD ST
Mailing Address - Street 2:
Mailing Address - City:MAHOMET
Mailing Address - State:IL
Mailing Address - Zip Code:61853-9097
Mailing Address - Country:US
Mailing Address - Phone:217-586-3460
Mailing Address - Fax:217-586-3523
Practice Address - Street 1:104 N LOMBARD ST
Practice Address - Street 2:
Practice Address - City:MAHOMET
Practice Address - State:IL
Practice Address - Zip Code:61853-9097
Practice Address - Country:US
Practice Address - Phone:217-586-3460
Practice Address - Fax:217-586-3523
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-14
Last Update Date:2020-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051294646183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist