Provider Demographics
NPI:1306029772
Name:ARDALAN, TRACY ELIZABETH (RPH)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:ELIZABETH
Last Name:ARDALAN
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1979 SENECA ST
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14210-2352
Mailing Address - Country:US
Mailing Address - Phone:716-827-4900
Mailing Address - Fax:716-827-4901
Practice Address - Street 1:1979 SENECA ST
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14210-2352
Practice Address - Country:US
Practice Address - Phone:716-827-4900
Practice Address - Fax:716-827-4901
Is Sole Proprietor?:No
Enumeration Date:2007-12-08
Last Update Date:2022-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY039450183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist