=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598036634
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MRS. ELIZABETH EDGE GRAY
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/20/2012
-----------------------------------------------------
Last Update Date | 01/20/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 102 S 2ND ST
-----------------------------------------------------
City | COCHRAN
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31014-6805
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 478-934-3868
-----------------------------------------------------
Fax | 478-934-3874
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 102 S 2ND ST
-----------------------------------------------------
City | COCHRAN
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31014-6805
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 478-934-3868
-----------------------------------------------------
Fax | 478-934-3874
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | RPH014912
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------