Provider Demographics
NPI:1235273475
Name:TRACYS PHARMACY
Entity Type:Organization
Organization Name:TRACYS PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RALPH
Authorized Official - Middle Name:
Authorized Official - Last Name:TRACY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-549-7716
Mailing Address - Street 1:637 PADGETT LOOP
Mailing Address - Street 2:
Mailing Address - City:WALTERBORO
Mailing Address - State:SC
Mailing Address - Zip Code:29488-4149
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:637 PADGETT LOOP
Practice Address - Street 2:
Practice Address - City:WALTERBORO
Practice Address - State:SC
Practice Address - Zip Code:29488-4149
Practice Address - Country:US
Practice Address - Phone:843-549-7716
Practice Address - Fax:843-549-6063
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-19
Last Update Date:2007-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
SC25713336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC700915Medicaid
4206997OtherOTHER ID NUMBER