Healthcare Provider Details

I. General information

NPI: 1649253857
Provider Name (Legal Business Name): JASON CHARLES GRAY PHARM D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/22/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

815 E 6TH ST CHICKASAW NATION HEALTH CLINIC
TISHOMINGO OK
73460-1800
US

IV. Provider business mailing address

2513 W MORROW RD
TISHOMINGO OK
73460-4226
US

V. Phone/Fax

Practice location:
  • Phone: 877-240-2720
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number13071
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: