Healthcare Provider Details

I. General information

NPI: 1619829892
Provider Name (Legal Business Name): STACEY GRAY CPHT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/11/2026
Last Update Date: 02/11/2026
Certification Date: 02/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

495 W 4TH ST
DOVE CREEK CO
81324-4900
US

IV. Provider business mailing address

150 MERCURY VILLAGE DR
DURANGO CO
81301-8955
US

V. Phone/Fax

Practice location:
  • Phone: 970-677-2291
  • Fax:
Mailing address:
  • Phone: 970-252-3200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License NumberPHAT.0019656
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: