Provider Demographics
NPI:1023731809
Name:GRAY, KHADIJAH NICOSHA
Entity type:Individual
Prefix:
First Name:KHADIJAH
Middle Name:NICOSHA
Last Name:GRAY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5653 SE MERCEDES AVE
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34997-8476
Mailing Address - Country:US
Mailing Address - Phone:772-233-1036
Mailing Address - Fax:
Practice Address - Street 1:575 W INDIANTOWN RD
Practice Address - Street 2:
Practice Address - City:JUPITER
Practice Address - State:FL
Practice Address - Zip Code:33458-3540
Practice Address - Country:US
Practice Address - Phone:561-746-8212
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-26
Last Update Date:2022-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS62109183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist