Provider Demographics
NPI:1285044081
Name:KENYON, TRACIE
Entity Type:Individual
Prefix:
First Name:TRACIE
Middle Name:
Last Name:KENYON
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 1:11619 RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH LYON
Mailing Address - State:MI
Mailing Address - Zip Code:48178-9319
Mailing Address - Country:US
Mailing Address - Phone:517-552-6610
Mailing Address - Fax:517-552-6665
Practice Address - Street 1:3883 E GRAND RIVER AVE
Practice Address - Street 2:
Practice Address - City:HOWELL
Practice Address - State:MI
Practice Address - Zip Code:48843-8564
Practice Address - Country:US
Practice Address - Phone:517-552-6610
Practice Address - Fax:517-552-6665
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-01
Last Update Date:2014-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53020254281835P1200X
FLPS391381835P1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1835P1200XOtherPHARMACIST-PHARMACOTHERAPY