Provider Demographics
NPI:1932431145
Name:RAY, SAMUEL CALVIN
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:CALVIN
Last Name:RAY
Suffix:
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 1:1300 MADISON AVE S
Mailing Address - Street 2:
Mailing Address - City:DOUGLAS
Mailing Address - State:GA
Mailing Address - Zip Code:31533-4404
Mailing Address - Country:US
Mailing Address - Phone:912-384-0144
Mailing Address - Fax:912-384-0252
Practice Address - Street 1:1300 MADISON AVE S
Practice Address - Street 2:
Practice Address - City:DOUGLAS
Practice Address - State:GA
Practice Address - Zip Code:31533-4404
Practice Address - Country:US
Practice Address - Phone:912-384-0144
Practice Address - Fax:912-384-0252
Is Sole Proprietor?:No
Enumeration Date:2010-02-12
Last Update Date:2010-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH016557183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist