Provider Demographics
NPI:1275883845
Name:HADDOCK, TRACEY
Entity Type:Individual
Prefix:DR
First Name:TRACEY
Middle Name:
Last Name:HADDOCK
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 1:15 W ASHLAND ST
Mailing Address - Street 2:
Mailing Address - City:ANDREWS
Mailing Address - State:SC
Mailing Address - Zip Code:29510-2543
Mailing Address - Country:US
Mailing Address - Phone:843-264-3291
Mailing Address - Fax:843-264-3291
Practice Address - Street 1:15 W ASHLAND ST
Practice Address - Street 2:
Practice Address - City:ANDREWS
Practice Address - State:SC
Practice Address - Zip Code:29510-2543
Practice Address - Country:US
Practice Address - Phone:843-264-3291
Practice Address - Fax:843-264-5425
Is Sole Proprietor?:No
Enumeration Date:2012-09-11
Last Update Date:2023-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC10818183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist