Provider Demographics
NPI:1326253063
Name:MARTIN, TRACEY DALE (PHARMACIST)
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:DALE
Last Name:MARTIN
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27 MOORE ST
Mailing Address - Street 2:
Mailing Address - City:TRION
Mailing Address - State:GA
Mailing Address - Zip Code:30753-1403
Mailing Address - Country:US
Mailing Address - Phone:706-734-2481
Mailing Address - Fax:706-734-7787
Practice Address - Street 1:49 HARRELL ST
Practice Address - Street 2:
Practice Address - City:TRION
Practice Address - State:GA
Practice Address - Zip Code:30753-1403
Practice Address - Country:US
Practice Address - Phone:706-734-2481
Practice Address - Fax:706-734-7787
Is Sole Proprietor?:No
Enumeration Date:2007-05-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH023029183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist