Provider Demographics
NPI:1063112688
Name:HALEY, RAY JR
Entity type:Individual
Prefix:
First Name:RAY
Middle Name:
Last Name:HALEY
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:180 KWANDO LN
Mailing Address - Street 2:
Mailing Address - City:BULLARD
Mailing Address - State:TX
Mailing Address - Zip Code:75757-3006
Mailing Address - Country:US
Mailing Address - Phone:903-316-3278
Mailing Address - Fax:
Practice Address - Street 1:5012 PROFIT DR
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75707-1839
Practice Address - Country:US
Practice Address - Phone:855-553-7200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-03
Last Update Date:2023-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH033548183500000X
LAPST.022861183500000X
OK17457183500000X
TX30703183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist