Provider Demographics
NPI:1205386141
Name:DAISE, TRACY NICOLE (PHARMD)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:NICOLE
Last Name:DAISE
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 1:3910 BUCKTHORNE DR UNIT E
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32065-5643
Mailing Address - Country:US
Mailing Address - Phone:904-236-9866
Mailing Address - Fax:
Practice Address - Street 1:3910 BUCKTHORNE DR UNIT E
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32065-5643
Practice Address - Country:US
Practice Address - Phone:904-236-9866
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-04
Last Update Date:2020-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS37842183500000X
GARPH029076183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPS37842OtherFL BOARD OF PHARMACY
GARPH029076OtherGA BOARD OF PHARMACY