Provider Demographics
NPI:1043858723
Name:BRANNON, TRACI LYNN (PHARM D)
Entity Type:Individual
Prefix:DR
First Name:TRACI
Middle Name:LYNN
Last Name:BRANNON
Suffix:
Gender:F
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 1:273 COUNTY ROAD 1170
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:TX
Mailing Address - Zip Code:76234-6217
Mailing Address - Country:US
Mailing Address - Phone:940-577-4845
Mailing Address - Fax:
Practice Address - Street 1:800 S HIGHWAY 287
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:TX
Practice Address - Zip Code:76234-1656
Practice Address - Country:US
Practice Address - Phone:940-627-3038
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-13
Last Update Date:2019-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX45516183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX45516OtherTEXAS STATE BOARD OF PHARMACY