Provider Demographics
NPI:1447575436
Name:MCCOY, TRACI REVELS (RPH)
Entity Type:Individual
Prefix:MRS
First Name:TRACI
Middle Name:REVELS
Last Name:MCCOY
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 1:702 W MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:GENEVA
Mailing Address - State:AL
Mailing Address - Zip Code:36340-1632
Mailing Address - Country:US
Mailing Address - Phone:334-684-0453
Mailing Address - Fax:334-684-9404
Practice Address - Street 1:702 W MAPLE AVE
Practice Address - Street 2:
Practice Address - City:GENEVA
Practice Address - State:AL
Practice Address - Zip Code:36340-1632
Practice Address - Country:US
Practice Address - Phone:334-684-0453
Practice Address - Fax:334-684-9404
Is Sole Proprietor?:No
Enumeration Date:2010-04-01
Last Update Date:2010-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL102190183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
1730216417OtherNPI
AL100000662Medicaid
AL100000662Medicaid