Provider Demographics
NPI:1003122417
Name:SIMMONS-KORNEGAY, TRACEY LYNN (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:TRACEY
Middle Name:LYNN
Last Name:SIMMONS-KORNEGAY
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:596 HALLSVILLE RD
Mailing Address - Street 2:
Mailing Address - City:BEULAVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28518-6600
Mailing Address - Country:US
Mailing Address - Phone:910-298-3350
Mailing Address - Fax:
Practice Address - Street 1:596 HALLSVILLE RD
Practice Address - Street 2:
Practice Address - City:BEULAVILLE
Practice Address - State:NC
Practice Address - Zip Code:28518-6600
Practice Address - Country:US
Practice Address - Phone:910-298-3350
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-23
Last Update Date:2010-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC16469183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist