=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225805823
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | REONNA SIMONE GRAY CPHT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/05/2023
-----------------------------------------------------
Last Update Date | 12/05/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4500 EUCLID AVE
-----------------------------------------------------
City | CLEVELAND
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44103-3736
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 216-438-2135
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4500 EUCLID AVE
-----------------------------------------------------
City | CLEVELAND
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44103-3736
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 216-438-2135
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183700000X
-----------------------------------------------------
Taxonomy Name | Pharmacy Technician
-----------------------------------------------------
License Number | 09304286
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------