Provider Demographics
NPI:1043429707
Name:HEAD, TRACY BETH (PHARMD, CGP)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:BETH
Last Name:HEAD
Suffix:
Gender:F
Credentials:PHARMD, CGP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:643 S. MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:DEFOREST
Mailing Address - State:WI
Mailing Address - Zip Code:53532
Mailing Address - Country:US
Mailing Address - Phone:608-846-2750
Mailing Address - Fax:608-846-2751
Practice Address - Street 1:643 S. MAIN STREET
Practice Address - Street 2:
Practice Address - City:DEFOREST
Practice Address - State:WI
Practice Address - Zip Code:53532
Practice Address - Country:US
Practice Address - Phone:608-846-2750
Practice Address - Fax:608-846-2751
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2012-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI14709-040183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist