Provider Demographics
NPI:1477502953
Name:ODOM, TRACY (RPH)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:ODOM
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 MAYHAW RD
Mailing Address - Street 2:
Mailing Address - City:COLQUITT
Mailing Address - State:GA
Mailing Address - Zip Code:39837-6938
Mailing Address - Country:US
Mailing Address - Phone:229-758-3763
Mailing Address - Fax:
Practice Address - Street 1:500 E ALICE ST
Practice Address - Street 2:
Practice Address - City:BAINBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:39819-4998
Practice Address - Country:US
Practice Address - Phone:229-246-9551
Practice Address - Fax:229-246-9574
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA018795183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist