MEDICARE: LEO S GRAY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	049890	NY

General Provider Information

NPI Number	:	1396926168
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LEO S GRAY

Provider Business Mailing Address
First Line	:	3910 BAYBERRY LN
Second Line	:
City	:	SEAFORD
State	:	NY
Zip	:	11783-1506
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	594 ATLANTIC AVE
Second Line	:
City	:	EAST ROCKAWAY
State	:	NY
Zip	:	11518-1539
Country	:	US
Telephone Number	:	516-599-2627
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/20/2007
Last Update Date	:	11/20/2007

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Directions to “ LEO S GRAY ” Practice Location

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