Provider Demographics
NPI:1801963681
Name:GRAY, RENARDO (RPH)
Entity type:Individual
Prefix:MR
First Name:RENARDO
Middle Name:
Last Name:GRAY
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16604 WESTBROOK ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48219-3894
Mailing Address - Country:US
Mailing Address - Phone:313-537-4249
Mailing Address - Fax:313-342-2120
Practice Address - Street 1:10600 W MCNICHOLS RD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48221-2366
Practice Address - Country:US
Practice Address - Phone:313-342-1555
Practice Address - Fax:313-342-2120
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302024134183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist