Healthcare Provider Details

I. General information

NPI: 1053455758
Provider Name (Legal Business Name): ROBERT W GRAY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/16/2007
Last Update Date: 06/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

47 MECHANIC ST EASTSIDE PUBLIC SQUARE
LYNCHBURG TN
37352
US

IV. Provider business mailing address

PO BOX 174
LYNCHBURG TN
37352-0174
US

V. Phone/Fax

Practice location:
  • Phone: 931-759-7329
  • Fax: 931-759-4604
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number0000000633
License Number StateTN

VIII. Authorized Official

Name: ROBERT GRAY
Title or Position: OWNER
Credential: DPH
Phone: 931-759-7329