Provider Demographics
NPI:1750897666
Name:MASSENGILL, RAY MCCLELLAN III
Entity type:Individual
Prefix:
First Name:RAY
Middle Name:MCCLELLAN
Last Name:MASSENGILL
Suffix:III
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15767 MONTICELLO DR
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:VA
Mailing Address - Zip Code:24202-4113
Mailing Address - Country:US
Mailing Address - Phone:276-591-7206
Mailing Address - Fax:
Practice Address - Street 1:15767 MONTICELLO DR
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:VA
Practice Address - Zip Code:24202-4113
Practice Address - Country:US
Practice Address - Phone:276-591-7206
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-15
Last Update Date:2017-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH017264183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist