Provider Demographics
NPI:1932232683
Name:BRAY, JACIENT D (R PH)
Entity Type:Individual
Prefix:MR
First Name:JACIENT
Middle Name:D
Last Name:BRAY
Suffix:
Gender:M
Credentials:R PH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1170 MCCAIN ST
Mailing Address - Street 2:
Mailing Address - City:BROCKWAY
Mailing Address - State:PA
Mailing Address - Zip Code:15824-1828
Mailing Address - Country:US
Mailing Address - Phone:814-265-2130
Mailing Address - Fax:
Practice Address - Street 1:411 MAIN ST
Practice Address - Street 2:
Practice Address - City:BROCKWAY
Practice Address - State:PA
Practice Address - Zip Code:15824-1324
Practice Address - Country:US
Practice Address - Phone:814-265-0050
Practice Address - Fax:814-265-0605
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP042532L183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PARP042532LOtherSTATE LICENSE