Provider Demographics
NPI:1083739296
Name:COZZOLINO, TRACY KAY
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:KAY
Last Name:COZZOLINO
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 1:7070 SE MCKINLEY ST
Mailing Address - Street 2:
Mailing Address - City:PORT ORCHARD
Mailing Address - State:WA
Mailing Address - Zip Code:98366-8446
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1141 BEACH DR E
Practice Address - Street 2:
Practice Address - City:PORT ORCHARD
Practice Address - State:WA
Practice Address - Zip Code:98366-4937
Practice Address - Country:US
Practice Address - Phone:360-895-4687
Practice Address - Fax:360-895-4482
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAVA00041465183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician