Healthcare Provider Details

I. General information

NPI: 1275231573
Provider Name (Legal Business Name): SHANNON GRAY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/16/2023
Last Update Date: 08/05/2026
Certification Date: 08/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

375 DIXMYTH AVE RM 560.1
CINCINNATI OH
45220-2475
US

IV. Provider business mailing address

4685 FOREST AVE
CINCINNATI OH
45212-3397
US

V. Phone/Fax

Practice location:
  • Phone: 513-569-6071
  • Fax: 513-852-3028
Mailing address:
  • Phone: 513-246-1964
  • Fax: 513-852-8525

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number03232689
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: