Provider Demographics
NPI:1477786788
Name:FENTRESS, TRACY L (RPH)
Entity Type:Individual
Prefix:MRS
First Name:TRACY
Middle Name:L
Last Name:FENTRESS
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 1:9775 SW GEMINI DR
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97008-7148
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9775 SW GEMINI DR
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97008-7148
Practice Address - Country:US
Practice Address - Phone:888-202-4014
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-02
Last Update Date:2020-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR8796183500000X, 1835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
No183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NAOtherNA
12341OtherNOT SURE
12341OtherPHARMACY