Provider Demographics
NPI:1104377837
Name:DONOVAN, TRACEY
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:
Last Name:DONOVAN
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 1:80 CLARK DR
Mailing Address - Street 2:
Mailing Address - City:EAST BERLIN
Mailing Address - State:CT
Mailing Address - Zip Code:06023-1157
Mailing Address - Country:US
Mailing Address - Phone:888-319-1818
Mailing Address - Fax:
Practice Address - Street 1:80 CLARK DR
Practice Address - Street 2:
Practice Address - City:EAST BERLIN
Practice Address - State:CT
Practice Address - Zip Code:06023-1157
Practice Address - Country:US
Practice Address - Phone:888-319-1818
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-18
Last Update Date:2016-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT8472183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist