Provider Demographics
NPI:1427523729
Name:GRAY, KYLE WAYNE (PHARM D)
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:WAYNE
Last Name:GRAY
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1416 SE MADISON ST
Mailing Address - Street 2:
Mailing Address - City:IDABEL
Mailing Address - State:OK
Mailing Address - Zip Code:74745-5718
Mailing Address - Country:US
Mailing Address - Phone:580-212-6889
Mailing Address - Fax:
Practice Address - Street 1:201 S PARK DR
Practice Address - Street 2:
Practice Address - City:BROKEN BOW
Practice Address - State:OK
Practice Address - Zip Code:74728-4737
Practice Address - Country:US
Practice Address - Phone:580-584-6085
Practice Address - Fax:866-307-8113
Is Sole Proprietor?:No
Enumeration Date:2018-10-12
Last Update Date:2018-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK17590183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist